Advice from an attending radiologist

[tum]

I was remembering the other day of my first time on here, reading through the forums, and how much gratitude I used to feel when an attending would come onto the forums and share an honest opinion that wouldn't dare be spoken of in the hallowed halls of academia or private practice.

Looking back, I wanted to share my own thoughts about the practice of radiology as I've seen it over the past several years. I would like to put in the caveat that I was originally in a "gunner specialty" for a few years before transferring, although now I practice solely as a radiologist.

Here are a few of the major concerns cited by radiologists in a panel at the RSNA about our major concerns as a specialty.

- Reimbursements are declining
- Malpractice is increasing - 3 out of 5 radiologists have been named in a suit; we are not the most liable specialty, but we are up there
- We have become comoditized
- The job market is abysmal

Many issues are obviously not unique to radiology. They do, however, appear to have manifest in our specialty in somewhat unique ways.

I had to wait several months after graduating from a top residency and fellowship to find a position that was reasonable as far as location. My co-fellows that matched quickly had to go rural or take pitiful jobs, irrespective of training. There is an inevitable lifestyle compromise for a city where the major attraction isn't a Walmart or county jail, but it is more dramatic than you might expect.

One may think teleradiology is a way around this, but the issue with going into tele is the multi state licensure and hospital accreditation required often make it difficult for you to find a position outside of tele later on. There is an inevitable component of practicing teleradiology that is Faustian. Once you check into the roach motel, you may never check out.

Having close friends and relatives across different medical subspecialties has also helped me realize something not always reflected in supposed online rankings of physician salaries. Usually, radiologists make about as much than generalists, and less than many, if not most, specialists.

Although the "easy ROAD" has developed a few pot holes, cuts to radiology are consistently the biggest by the Congressional Budget Office. The AMA, unfortunately, does not care about us as a specialty, and often throws us under the bus when it comes time to their lobbying the Policy and Steering Committee. You can check the published minutes if you don't believe me. The ACR is of questionable competency and has often suffered from a severe lack of leadership. The recalls debacle, for example, was a prime example of the disconnect between our leadership and practicing body.

If you could hear the conversations happening behind closed doors that we have, you would quickly realize that while the economy as a whole may be starting to reawaken, radiology itself is still dead in the water. This has distorted the climate of both academic and private practice to one that is exceptionally cutthroat.

I remember about 10-15 years ago when I was earlier in my training, people kept saying, "This is a cycle, this is a cycle." Then about 3-4 years ago, the conversation changed. Now it sounds more like: "Hey, you know what? Maybe this isn't a cycle."

If you deeply enjoy studying and sitting in front of a computer with the feeling of being under a constant time pressure, radiology is for you (although path is not bad). If you love radiology research and are willing to put up with the rat race that RO1s and the NIH have become, then radiology is for you.

The take home is this: there are no major economic windfalls in medicine that won't require an unusual amount of entrepreneurial savvy. Educate yourself, advocate for yourself, and always have an exit strategy. The money and lifestyle the specialty once had are nothing more than echoes of a former greatness. Good luck friends.

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[qwerty89]

Looking at your post history you went to a good IM program in Texas (gunner specialty?) with likely great prospects for GI, Cards, Heme/Onc, AI, etc. With that in mind the question is would you do it again or would you stick with IM + fellowship?

Also if you could, please PM me with typical salaries of radiologists these days in PP/employed positions.

- current M4 applying rads

 

[scootad.]

As another attending radiologist, I agree with the OP. I will add that these days its imperative to have a strong work ethic. High volumes today. I enjoy radiology but I also don't mind working relatively hard (I happen to be a fast reader though). I have seen many of my colleagues (the ones with a poor work ethic) miserable in both residency and in their jobs, because they expected radiology to be a cakewalk requiring little work. Historically radiology has attracted the lazy candidates. If you at all have lazy tendencies, I would pick a different field.

I am happy with my choice. I find radiology has just the right amount of patient contact, doesn't have to deal with annoying social issues, and I feel that my work is valued.

 

[colbgw02]

As another attending radiologist, I agree with the OP. I will add that these days its imperative to have a strong work ethic. High volumes today. I enjoy radiology but I also don't mind working relatively hard (I happen to be a fast reader though). I have seen many of my colleagues (the ones with a poor work ethic) miserable in both residency and in their jobs, because they expected radiology to be a cakewalk requiring little work. Historically radiology has attracted the lazy candidates. If you at all have lazy tendencies, I would pick a different field.

I am happy with my choice. I find radiology has just the right amount of patient contact, doesn't have to deal with annoying social issues, and I feel that my work is valued.

I don't share a lot of the OP's pessimism, but I agree with this. The pay is still pretty good, but private practice radiology stopped being a lifestyle specialty awhile ago. For interested students, the workload that you see for academic attendings is much less than what you'll see in PP. It's also one of those specialties where the residency workload is appreciably less than life as an attending. Combined, I think this leads to a lot of misconceptions about what will be expected of you after training.

 

[shark2000]

As another attending radiologist, I agree with the OP. I will add that these days its imperative to have a strong work ethic. High volumes today. I enjoy radiology but I also don't mind working relatively hard (I happen to be a fast reader though). I have seen many of my colleagues (the ones with a poor work ethic) miserable in both residency and in their jobs, because they expected radiology to be a cakewalk requiring little work. Historically radiology has attracted the lazy candidates. If you at all have lazy tendencies, I would pick a different field.

I am happy with my choice. I find radiology has just the right amount of patient contact, doesn't have to deal with annoying social issues, and I feel that my work is valued.

As another attending radiologist, I am also very happy with my choice. Kind of similar to you. I am also a fast reader and working in a very high volume practice. The volume is just a little more than I want it to be, but overall I am fine and don't feel exhausted. One of our new associates left recently because he could not handle the volume. There is another associate who has a very hard time keeping up with the volume. On the other hand, the compensation is very good in my group. Without getting into numbers, I get paid more than most other physicians.

I totally agree with the above post. If you choose radiology because you think it is easy, do something else. My diagnostic working days are from 7:30 in the morning to 7:00 PM almost without any lag. I spend 1/3 of my time doing procedures like biopsies, drains, basic IR and spine procedures (injections, kypho, vertebro). You get surprised if I tell you that on my procedure day I work less than my diagnostic days since at least there are some free time between cases.

There are a lot of disgruntled radiologist out there. It does not mean that the field is not satisfying. But as scootad mentioned, the field traditionaly attracted lazier candidates. As result, too many complaints about working after 5 PM or on weekends or night shifts. Unfortunately, still a lot of medical students choose radiology for life-style reasons. As I mentioned multiple times in my previous posts, this is not a life-style field anymore. Not uncommon for a medical student to choose IR over surgery because of the very false impression that IR has better hours. In reality, a good number of surgical subspecialties definitely have better hours than IR.

 

[shark2000]

It seems that colbgw02 and I were writing our posts at the same time without knowing about each others posts. And we both have very similar perspectives. colbgw02, are you MSK trained? I did MSK fellowship but do almost everything in my pp. Probably I am less focused on MSK than many other MSK radiologists which is totally fine with me.

 

[scootad.]

We just had someone leave my PP most likely because it was "too busy." In reality I don't consider it any busier than most PP. ~60-80 x rays, 20 US, 20 mammos on one day, 10-15 MRI, 8-12 CTs the other day (i.e. person reading CT/MRI is only responsible for reading CT/MRI, while person B reading the other stuff is only responsible for xr, us, mammos. I think this person had unrealistic expectations of PP and would have been better suited for VA job or a different field.

 

[colbgw02]

It seems that colbgw02 and I were writing our posts at the same time without knowing about each others posts. And we both have very similar perspectives. colbgw02, are you MSK trained? I did MSK fellowship but do almost everything in my pp. Probably I am less focused on MSK than many other MSK radiologists which is totally fine with me.

PM incoming.

 

[colbgw02]

We just had someone leave my PP most likely because it was "too busy." In reality I don't consider it any busier than most PP. ~60-80 x rays, 20 US, 20 mammos on one day, 10-15 MRI, 8-12 CTs the other day (i.e. person reading CT/MRI is only responsible for reading CT/MRI, while person B reading the other stuff is only responsible for xr, us, mammos. I think this person had unrealistic expectations of PP and would have been better suited for VA job or a different field.

Unless those are all diagnostics with a high percentage of biopsies, neither of those days sounds bad at all.

 

[shark2000]

Some people can not keep up with the volume. In the past the volume was less and VA and academic jobs were widely available. They were able to find the job that fit them well, though they always bit$$ed and moaned about how their classmates made a bank in pp. In the last 4-5 years the market for VA and academic jobs have dried up fast and they have to take whatever job comes by. Now they are all over in auntminnie and complain about their horrible situation.

We had an associate who left a few months ago because she wanted a 9-4 job to read 2 CTs per hour and take an hour of lunch break. She didn't want any weekends or any night shifts. Having said that, I don't blame her because she never expected to make a high salary. In fact, she was happy with primary care level salary. Unfortunately, esp in our competitive market you can not find a part time job unless you are a family doctor or a psychiatrist or a well established clinician in an outpatient field OR if you join VA or academics.

Bottom line: The market is tight and you can not dictate what you want to do. It is all or none. In theory, radiology seems a very good fit for people who want to work part time because it doesn't have continuity of care. In practice, it is the exact opposite. Part time job does not exist in my area even if you are willing to get a huge pay cut unless you are the senior partner and own the business.

 

[pathologyDO]

This is not for any particular poster.. but I feel like every specialty forum says the same thing. "Oh if you want lifestyle this is not it." "If you're looking for good pay, think again, salary is dropping." It seems like these types of changes are happening in every specialty and that really makes it hard to take those statements with much more than a grain of salt.

Let me ask you guys this - say a student like myself wants to make a specialist range salary, work good physician hours (I emphasize physician because I realize that physician hours are generally much higher than say 40 hrs/wk), and of course importantly enjoy their work and not be miserable due to irritations inherent with the field. Rads seems great but comments like the ones previously listed seem to imply there are much better options to consider for people with the stats needed to match rads. What are those fields?

(I think what I'm trying to tell you here is that I am super interested in rads and am basically set on it, and am being argumentative to prove my own thoughts on why I don't listen to the gloom and doom. But I am seriously interested in responses)

 

[vm26]

This is not for any particular poster.. but I feel like every specialty forum says the same thing. "Oh if you want lifestyle this is not it." "If you're looking for good pay, think again, salary is dropping." It seems like these types of changes are happening in every specialty and that really makes it hard to take those statements with much more than a grain of salt.

Let me ask you guys this - say a student like myself wants to make a specialist range salary, work good physician hours (I emphasize physician because I realize that physician hours are generally much higher than say 40 hrs/wk), and of course importantly enjoy their work and not be miserable due to irritations inherent with the field. Rads seems great but comments like the ones previously listed seem to imply there are much better options to consider for people with the stats needed to match rads. What are those fields?

(I think what I'm trying to tell you here is that I am super interested in rads and am basically set on it, and am being argumentative to prove my own thoughts on why I don't listen to the gloom and doom. But I am seriously interested in responses)

Derm, ortho, anesthesia, GI, GU, hospitalist (work like a dog but will make similar to rads who work like dogs), ER, heme-onc

 

[scootad.]

Because today's volumes are high, having good speed (accuracy is a given), is at a premium. The radiologists that I have seen struggle and end up not being happy are the slow ones. Whether they are slow because they a) lack confidence b) are afraid of getting sued c) write redundant, long reports that never get to the point d) are lazy or e) combination of all the above - is debatable. But what's not debatable is that the slow ones are the radiologists that end up miserable in the field. Whether you will be a fast, avg speed or slow radiologist is impossible to predict before entering residency, but becomes obvious once you start taking call halfway through. This unfortunately will be what determines whether you will be happy or not with the field. If you are fast and accurate, there is a good chance you will find rads to be a desirable field and not regret your decision.

The other issue that I haven't covered is finding a job that is outpatient vs. hospital based which could make a difference in M-F 8-5 hours or having to work on weekends. Admittedly, outpatient only PP are becoming more rare, but they are definitely still out there, and I in fact work at one. Whether they will still be there in 10-15 years remains to be seen.

 

[pathologyDO]

Derm, ortho, anesthesia, GI, GU, hospitalist (work like a dog but will make similar to rads who work like dogs), ER, heme-onc

That is my point. If you still work roughly similar hours then how is it that those fields are better?

Derm = very, very competitive

Anesthesiology = payments decreasing, no longer do same job now they supervise nurses that do the job. Still work hard hours and when **** hits the fan (and it apparently does often) then things get stressful quick (in other words acute -> chronic stress.. doesn't sound better/worse than rads stress)

Ortho = hard hours, grueling residency (gramps was an orthopedist, I know from experience how often he was on call and the hours he worked)

GI = super competitive IM subspecialty and if you don't get into it you're stuck in IM (risky), hours would not be any better than rads

GU (urology?) = very competitive, otherwise a decent option for those with the stats and passion for the field

ER = work on holidays/weekends often, high burnout rate, switching from nights to days will always be needed and in older age could get very tiring (you probably don't see

hospitalist = not interested.

Heme-Onc = high hours, hard work, competitive IM subspecialty (again risky)

If you look at that crude list above, you can see each of these fields has a significant problem that you can easily argue makes them no better than the problems in rads, aka "lowering pay, harder work." This is why I argue that for people like me interested in rads, those factors mean very little.

 

[scootad.]

The last thing I would add is I would probably regret the field if I had to do teleradiology. I hate the idea of working for a large mega corporation, skimming my profits, making me read ever larger #s of studies every year to even make the same amount, with zero say in how my job is run. Its also a career dead end. Very difficult to transition out of telerads once you enter. So I would avoid rads if I had to do telerad.

 

[vm26]

I was remembering the other day of my first time on here, reading through the forums, and how much gratitude I used to feel when an attending would come onto the forums and share an honest opinion that wouldn't dare be spoken of in the hallowed halls of academia or private practice.

Looking back, I wanted to share my own thoughts about the practice of radiology as I've seen it over the past several years. I would like to put in the caveat that I was originally in a "gunner specialty" for a few years before transferring, although now I practice solely as a radiologist.

Here are a few of the major concerns cited by radiologists in a panel at the RSNA about our major concerns as a specialty.

- Reimbursements are declining
- Malpractice is increasing - 3 out of 5 radiologists have been named in a suit; we are not the most liable specialty, but we are up there
- We have become comoditized
- The job market is abysmal

Many issues are obviously not unique to radiology. They do, however, appear to have manifest in our specialty in somewhat unique ways.

I had to wait several months after graduating from a top residency and fellowship to find a position that was reasonable as far as location. My co-fellows that matched quickly had to go rural or take pitiful jobs, irrespective of training. There is an inevitable lifestyle compromise for a city where the major attraction isn't a Walmart or county jail, but it is more dramatic than you might expect.

One may think teleradiology is a way around this, but the issue with going into tele is the multi state licensure and hospital accreditation required often make it difficult for you to find a position outside of tele later on. There is an inevitable component of practicing teleradiology that is Faustian. Once you check into the roach motel, you may never check out.

Having close friends and relatives across different medical subspecialties has also helped me realize something not always reflected in supposed online rankings of physician salaries. Usually, radiologists make about as much than generalists, and less than many, if not most, specialists.

Although the "easy ROAD" has developed a few pot holes, cuts to radiology are consistently the biggest by the Congressional Budget Office. The AMA, unfortunately, does not care about us as a specialty, and often throws us under the bus when it comes time to their lobbying the Policy and Steering Committee. You can check the published minutes if you don't believe me. The ACR is of questionable competency and has often suffered from a severe lack of leadership. The recalls debacle, for example, was a prime example of the disconnect between our leadership and practicing body.

If you could hear the conversations happening behind closed doors that we have, you would quickly realize that while the economy as a whole may be starting to reawaken, radiology itself is still dead in the water. This has distorted the climate of both academic and private practice to one that is exceptionally cutthroat.

I remember about 10-15 years ago when I was earlier in my training, people kept saying, "This is a cycle, this is a cycle." Then about 3-4 years ago, the conversation changed. Now it sounds more like: "Hey, you know what? Maybe this isn't a cycle."

If you deeply enjoy studying and sitting in front of a computer with the feeling of being under a constant time pressure, radiology is for you (although path is not bad). If you love radiology research and are willing to put up with the rat race that RO1s and the NIH have become, then radiology is for you.

The take home is this: there are no major economic windfalls in medicine that won't require an unusual amount of entrepreneurial savvy. Educate yourself, advocate for yourself, and always have an exit strategy. The money and lifestyle the specialty once had are nothing more than echoes of a former greatness. Good luck friends.

Thank you for your insight... The field is tight, I agree that this is no longer a cycle...I think one can do well but it is a numbers game (recently interviewed for a desirable job in a good location having done 2fellowships, they told me they received over 100 cv's). One has to be willing to work hard and plow through studies, with a little luck and perseverance you can land a good gig, however many new radiologists will struggle unfortunately

 

[pathologyDO]

Because today's volumes are high, having good speed (accuracy is a given), is at a premium. The radiologists that I have seen struggle and end up not being happy are the slow ones. Whether they are slow because they a) lack confidence b) are afraid of getting sued c) write redundant, long reports that never get to the point d) are lazy or e) combination of all the above - is debatable. But what's not debatable is that the slow ones are the radiologists that end up miserable in the field. Whether you will be a fast, avg speed or slow radiologist is impossible to predict before entering residency, but becomes obvious once you start taking call halfway through. This unfortunately will be what determines whether you will be happy or not with the field. If you are fast and accurate, there is a good chance you will find rads to be a desirable field and not regret your decision.

The other issue that I haven't covered is finding a job that is outpatient vs. hospital based which could make a difference in M-F 8-5 hours or having to work on weekends. Admittedly, outpatient only PP are becoming more rare, but they are definitely still out there, and I in fact work at one. Whether they will still be there in 10-15 years remains to be seen.

That is scary.

Do you think there may be any characteristics that make a person a faster radiologist? Do you think those that read films faster are: faster test takers, fast at reading a book, faster at writing, better at where is waldo (only slightly joking on that one)?

 

[scootad.]

Do you think there may be any characteristics that make a person a faster radiologist? Do you think those that read films faster are: faster test takers, fast at reading a book, faster at writing, better at where is waldo (only slightly joking on that one)?

This is a great question. Its multifactorial. Having experience, seeing lots of patterns of different types of fractures and diseases, your eyes go directly to the abnormality quicker. Its also about being able to summarize findings concisely, and being able to convey ideas in few words while still getting your point across clearly. You see something abnormal, are not quite clear what it is, but give the 2 or 3 most likely possibilities (including the most serious ones that will need followup or kill the patient). I think therefore a lot of it is style. The longwinded rads are their own worst enemies. The problem is when you are in residency you might be learning bad habits from the academics with styles that just don't translate well to PP.

 

[vm26]

That is my point. If you still work roughly similar hours then how is it that those fields are better?

Derm = very, very competitive

Anesthesiology = payments decreasing, no longer do same job now they supervise nurses that do the job. Still work hard hours and when **** hits the fan (and it apparently does often) then things get stressful quick (in other words acute -> chronic stress.. doesn't sound better/worse than rads stress)

Ortho = hard hours, grueling residency (gramps was an orthopedist, I know from experience how often he was on call and the hours he worked)

GI = super competitive IM subspecialty and if you don't get into it you're stuck in IM (risky), hours would not be any better than rads

GU (urology?) = very competitive, otherwise a decent option for those with the stats and passion for the field

ER = work on holidays/weekends often, high burnout rate, switching from nights to days will always be needed and in older age could get very tiring (you probably don't see

hospitalist = not interested.

Heme-Onc = high hours, hard work, competitive IM subspecialty (again risky)

If you look at that crude list above, you can see each of these fields has a significant problem that you can easily argue makes them no better than the problems in rads, aka "lowering pay, harder work." This is why I argue that for people like me interested in rads, those factors mean very little.

When I matched in rads in 2007, competitiveness was similar to ortho,GU, derm, high end IM (leading to GI/hemeonc/cards etc)...if you are entering rads now you will be working evening, weekends, holidays, and possibly nights, and if currents trends continue burnout (eat what you kill) will also be an issue. if you're ok with this then you will do fine in this field.

 

[vm26]

That is scary.

Do you think there may be any characteristics that make a person a faster radiologist? Do you think those that read films faster are: faster test takers, fast at reading a book, faster at writing, better at where is waldo (only slightly joking on that one)?

Very small percentage of rads are both fast and accurate (sorta like being a big and fast defensive end In the nfl), I worked in a pp for a year that had extremely high-volume readers (18-22k rvus/yr) , for the most part the faster readers had the most concise reports and were also most prone to misses (and oftentimes where most complained about from referers)...I have also known brilliant rads who were slow as molasses in winter, they had to mention every detail, a lot of speed is mentality IMHO

 

[scootad.]

That has not been my experience. In 3.5 years of PP, most complaints I've seen from referrers have been regarding radiologist reports that are indecisive, wordy (and full of radiology jargon only understandable to radiologists), and recommend too many extra exams without clear reasoning as to why, therefore handcuffing the referrers.

 

[colbgw02]

Very small percentage of rads are both fast and accurate (sorta like being a big and fast defensive end In the nfl), I worked in a pp for a year that had extremely high-volume readers (18-22k rvus/yr) , for the most part the faster readers had the most concise reports and were also most prone to misses (and oftentimes where most complained about from referers)...I have also known brilliant rads who were slow as molasses in winter, they had to mention every detail, a lot of speed is mentality IMHO

Strongly disagree with this, although it depends on how we're defining those terms. I know radiologists who consider a report "inaccurate" if it doesn't mention a splenule. And what is considered fast? In this thread, we have someone citing radiologists changing jobs because <30 cross-sectional studies per day is too much, but I would hardly consider that workload to require being fast. Regarding speed, I think it's highly personal. One person's error rate my go up at X speed, while the next person can read at 2X with fewer errors. It's self-evident to me that everyone has a tipping point, beyond which they become unsafe, but we can't determine that point collectively.

 

[colbgw02]

Do you think there may be any characteristics that make a person a faster radiologist? Do you think those that read films faster are: faster test takers, fast at reading a book, faster at writing, better at where is waldo (only slightly joking on that one)?

Some people are just faster processors than others. There's something to be said for the adage "often wrong, but never in doubt". That said, getting faster is still a skill that can be learned and developed. A good part of it is just experience, and starting to take call helps a lot too. But I think residents need to have a sense of urgency about how much they're "seeing". A lot of the residents I see are perfectly content to just read a handful of studies a day, either not caring about developing speed or figuring they're work on it as a fellow/young attending.

Also, I think too few radiologists (and physicians in general, for that matter) have a strong background in writing, probably because we tend to be math and science heavy in our pre-medical school lives. I happened to attend a university where I would go entire semesters graded entirely by papers and essay tests, to include in my biology and chemistry courses. It really taught me how to pare down a sentence, cut out fluff, and be a wordsmith. Teaching a resident how to do this is really beyond the scope of GME. It's a skill that ideally needs to be in place before you get to radiology.

 

[Gadofosveset]

Very small percentage of rads are both fast and accurate (sorta like being a big and fast defensive end In the nfl), I worked in a pp for a year that had extremely high-volume readers (18-22k rvus/yr) , for the most part the faster readers had the most concise reports and were also most prone to misses (and oftentimes where most complained about from referers)...I have also known brilliant rads who were slow as molasses in winter, they had to mention every detail, a lot of speed is mentality IMHO

I would argue that this is true. Given the same level of skill and knowledge, the problem is inherently one for the ROC curve. If skill and effort are held constant, faster radiologists miss more things and slower radiologists tend to miss fewer things.

One could argue that not every splenule needs to be mentioned for an accurate report. This is true.
One could argue that academic radiologists are slow for many reasons other than an excruciating need for perfection. Any experience with them shows this also to be true.

But pp radiologists pat themselves on the back a little too much over their own prowess. Any time spent overreading community reports at an academic center quickly shows how accurate average pp reports are. The pp skill is to maximize speed while minimizing actionable error rate, but in my experience, for anything other than a bread and butter case they fall apart, because they're clearly in too much of a hurry to actually get it right (I'm thinking MRI body since that's mostly my area). For every referring clinician mentioning a verbose academic report, I've met a clinician asking why the hell a community radiologist called an FNH an HCC.

The point is that, given the same skill level, one can't have it all. The idea that pp radiolgists are just in another league of skill compared with academic radiologists is questionable, and probably based on the bias of pp radiologists not seeing their mistakes ("You get paid the same for a wrong report as for a right one" has been mentioned to me).

I would also agree that one has to have a commitment to efficiency, which many residents do not attempt in their training. I've made the effort over time (as mentioned, this is not expected in training) to experiment on myself to increase efficiency, timing myself at one aspect or another to find potential hang ups. To echo previous posters, I've generally found that I have the diagnosis in about 1 second, but reading old reports, comparing with old images, and editing the report is where all the time is spent. I would echo the comment above about being trained in writing and paring down one's sentences.

Ultimately you have to be comfortable with where you are on the ROC curve. There are pros and cons to both extremes which are unavoidable. If you don't like where you are on the curve, change it. I try to be somewhere in the middle, which usually makes persons at both extremes upset, but which seems to make the most sense to me. I also make a commitment to gradually increasing the area under my curve. There's a patient at the other end of the report to whom I owe some medical responsibility... I'm a doctor first and radiologist second; extremists in both pp and academics tend to forget this, I think.

 

[scootad.]

There's a balance for sure. You definitely can't generalize that ALL academics are too longwinded and ALL PP are too cursory. At the same time, there is no abnormality too complicated that it can't be summarized neatly into a 2 paragraph report. And IMO no radiologist should routinely have reports with 10 item impressions. This is what damages our specialty the most. I will say that some of the absolute worst reports and misses I've seen have come from telerads. (Of course this is anecdotal).

 

[vm26]

But pp radiologists pat themselves on the back a little too much over their own prowess. Any time spent overreading community reports at an academic center quickly shows how accurate average pp reports are. The pp skill is to maximize speed while minimizing actionable error rate, but in my experience, for anything other than a bread and butter case they fall apart, because they're clearly in too much of a hurry to actually get it right (I'm thinking MRI body since that's mostly my area). For every referring clinician mentioning a verbose academic report, I've met a clinician asking why the hell a community radiologist called an FNH an HCC.

There is a certain prowess/swagger that pp rads have related to their volume and clearing the list, and to be honest there are some who are quite impressive in their accuracy/speed combo but like I alluded to before I do think these are the outliers (?5-10% of rads). One does get to see some dubious reads from community radiologists (recently a request to biopsy an unusual pattern of focal fatty deposition before even suggesting a mri) but we all make mistakes and eat humble pie. Also have seen ridiculously verbose academic reports that are more confusing than helpful...

 

[vm26]

The point is that, given the same skill level, one can't have it all. The idea that pp radiolgists are just in another league of skill compared with academic radiologists is questionable, and probably based on the bias of pp radiologists not seeing their mistakes ("You get paid the same for a wrong report as for a right one" has been mentioned to me).

Have also heard one pp rad mention to me that if you aren't missing things regularly then you are not reading fast enough. Another fast reader told me he decided on becoming fast after he became sick of leaving work at 10pm rather than 6pm. I cannot speak for his miss rate but this sorta speaks to the mentality/attitude one needs to have since I do not think this particular rad all of a sudden was able to process things at a much faster level. For better or worse this is the current state of things.

 

[atomi]

That is my point. If you still work roughly similar hours then how is it that those fields are better?

Derm = very, very competitive

Anesthesiology = payments decreasing, no longer do same job now they supervise nurses that do the job. Still work hard hours and when **** hits the fan (and it apparently does often) then things get stressful quick (in other words acute -> chronic stress.. doesn't sound better/worse than rads stress)

Ortho = hard hours, grueling residency (gramps was an orthopedist, I know from experience how often he was on call and the hours he worked)

GI = super competitive IM subspecialty and if you don't get into it you're stuck in IM (risky), hours would not be any better than rads

GU (urology?) = very competitive, otherwise a decent option for those with the stats and passion for the field

ER = work on holidays/weekends often, high burnout rate, switching from nights to days will always be needed and in older age could get very tiring (you probably don't see

hospitalist = not interested.

Heme-Onc = high hours, hard work, competitive IM subspecialty (again risky)

If you look at that crude list above, you can see each of these fields has a significant problem that you can easily argue makes them no better than the problems in rads, aka "lowering pay, harder work." This is why I argue that for people like me interested in rads, those factors mean very little.

I think your post has already introduced this idea, but the job you are looking for does not exist in medicine or any other industry. The max you can earn anywhere doing low-stress work is around $75-100k/year. Anything beyond that comes with high stress, responsibility, credentialing/ladder-climbing, job/income insecurity (a fat salary makes you easy pickins when the company/industry needs to downsize or reduce costs), high productivity requirements, and long hours. This is true in any industry. If you go out on your own, you can make a living with high income and low stress, but this comes with the added prerequisites of a unique skill/idea, a grueling period of establishing your business, and high risk. And as someone who did well on his own briefly, let me tell you the stress never goes away even if your work is easy because there is zero security and you never know when your golden goose is going to die. Plenty of people say screw it and live happily on lower incomes because the trade off isn't worth it (how many nurses thought about becoming doctors instead?). The problem in medicine for a long time is people viewing it as an exception thinking they can make the big bucks with low stress work and suck up a few years of painful residency. Obviously they're not going to be happy when they get pushed because they didn't sign up for that.

Occasionally a "hot" field pops up where people make big $$ with little investment for low stress work. These never last long. You might even call many sub specialties in the 80s "hot fields" that busted as work requirements went up and incomes went down.

The closest thing you're going to get right now is dermatology, and its days are likely numbered too.

That all being said, I think people should try to become good at something they enjoy doing and make a career out of it. If you don't like medicine because you're scared that it might end up being high stress, high hour, low security work then you might need to find another line of work and adjust your income expectations. My buddy has been a waiter for 15 years. He makes 500-1000/week and his job is very low stress and no responsibility. He literally bounces around the country and finds work everywhere he lands within a matter of days. He lives carefree without a worry in the world despite never having more than a few hundred bucks in his bank account at any time. Obviously, his life style is not for all of us and there are a million shades of gray between him and the CEO of an investment bank, but hopefully this illustrates my point.

 

[shark2000]

Have also heard one pp rad mention to me that if you aren't missing things regularly then you are not reading fast enough. Another fast reader told me he decided on becoming fast after he became sick of leaving work at 10pm rather than 6pm. I cannot speak for his miss rate but this sorta speaks to the mentality/attitude one needs to have since I do not think this particular rad all of a sudden was able to process things at a much faster level. For better or worse this is the current state of things.

Somehow disagree.

You can be a fast reader and still not miss IMPORTANT findings more than others. One thing that you learn is how to differentiate between important findings and irrelevant unimportant findings that only exist in academics. After reading fast for a while, your brain will learn how to automatically dismiss unimportant details and focus on important findings.
One problem with new trainees is their huge disconnect from efficacy because this is how radiology is being taught in academics. You can just mention that there is a simple renal cyst rather than describing it for 2 lines.

Slow readers don't necessarily spend their time improving the quality of reports or interpretations. Interpretation of an imaging study is sort of multitasking combined with prompt decision making. Some people, no matter how good or bad can not make a prompt decision. Also some people are better at multitasking.

 

[scootad.]

You can just mention that there is a simple renal cyst rather than describing it for 2 lines. Slow readers don't necessarily spend their time improving the quality of reports or interpretations.

+1. For instance the rad who is leaving routinely mentions every cyst (with 3 dimensional measurements), every calcified granuloma, every pelvic phlebolith. It makes the reports wordy, overly complicated, and unhelpful to the clinician. And I can't help but cringe when I see his list multiplying (he of course cannot stay on top of it). Its a no brainer why he can't get his work done.

I can kind of understand why residencies want you describe all the unimportant incidentals in the first couple years, but really by R4 reports need to be more bare bones and clinically relevant. Its unfortunate we don't make this a priority before graduating. As radiologists, alot of the times, 99% of our worth is our report (excepting biopsies and procedures of course).

I almost think the board exams should have a component requiring you read an exam and create a short, efficient report.

 

[vm26]

Somehow disagree.

You can be a fast reader and still not miss IMPORTANT findings more than others. One thing that you learn is how to differentiate between important findings and irrelevant unimportant findings that only exist in academics. After reading fast for a while, your brain will learn how to automatically dismiss unimportant details and focus on important findings.
One problem with new trainees is their huge disconnect from efficacy because this is how radiology is being taught in academics. You can just mention that there is a simple renal cyst rather than describing it for 2 lines.

Slow readers don't necessarily spend their time improving the quality of reports or interpretations. Interpretation of an imaging study is sort of multitasking combined with prompt decision making. Some people, no matter how good or bad can not make a prompt decision. Also some people are better at multitasking.

My logic (and math) may be faulty but consider this, reader A dictates 200 studies/day and reader B dictates 100 studies/day. Faster reader A has a miss rate of 5% while reader B, while slower, has a higher miss rate of 8%. Each day reader A has 10 miss's and reader B has 8 miss's. Reader A while more accurate will have way more misses inherent to their volume. If slower reader B is as accurate or more accurate, then the differences would be even greater. This is where the mentality aspect goes into play, fast readers have to be more comfortable with potential misses in light of taking less time per study and shear volume

I don't disagree that slow readers (typically verbose and/or indecisive) do not necessarily improve quality and in fact they often add confusion

 

[meister]

No, the boards are much more relevant to practice being 50% physics, nucs and cardiac!

 

[vm26]

I can kind of understand why residencies want you describe all the unimportant incidentals in the first couple years, but really by R4 reports need to be more bare bones and clinically relevant. Its unfortunate we don't make this a priority before graduating. As radiologists, alot of the times, 99% of our worth is our report (excepting biopsies and procedures of course).

I almost think the board exams should have a component requiring you read an exam and create a short, efficient report.

Agree there is huge disconnect between training and what is required in the real-world. As trainees we are taught to describe every observation and somehow reports are deemed incomplete if you didn't mention the splenule or bone island.

 

[meister]

We could devote an entire thread to meaningless radiology report information.

 

[Gadofosveset]

+1. For instance the rad who is leaving routinely mentions every cyst (with 3 dimensional measurements)...).

Three points for completeness' sake:

1) For reports, patient populations, PPV, and clinician expectations are important. If I forget to mention a splenule on a melanoma patient, you better believe the local oncologist is gonna give me a call. He has. I would say this stuff about "clinician expectations" is pretty much a wash. For every clinician who wants less information in a report, I meet one who wants more.

2) The discussion about what is "important" is actually more subtle than might at first seem. As most of us know, you only see what you look for (as demonstrated with the CT chest gorilla experiment). The argument some radiologists make against going too fast is that one is unable to adapt to something outside of one's expectations. Actually thinking and not just reacting in a hard-wired way will necessarily slow you down... being careful will also slow you down... but the thinking and the careful analysis is also how the radiologist adds value. Sloppily cranking through cases adds little value... hedging is also fast work and they really hate that. Clinicians can sense a quick and sloppy radiology report, just as you can sense a sloppy H&P.

3) I think the best analogy is a well-written H&P. We all have a good feeling for what it looks and feels like. I don't care about whether the patient has any cats at home or if they wear seatbelts. But I want more relevant information... I want to know I can go to it for the information I need. I need it in a predictable well-organized manner. I would like it to be thoughtfully put together. Someone who cranks out a crap H&P because "why bother, who reads it?" is not doing the patient a service and his or her rationalizations are ultimately self-serving.

 

[colbgw02]

Three points for completeness' sake:

1) For reports, patient populations, PPV, and clinician expectations are important. If I forget to mention a splenule on a melanoma patient, you better believe the local oncologist is gonna give me a call. He has. I would say this stuff about "clinician expectations" is pretty much a wash. For every clinician who wants less information in a report, I meet one who wants more.

2) The discussion about what is "important" is actually more subtle than might at first seem. As most of us know, you only see what you look for (as demonstrated with the CT chest gorilla experiment). The argument some radiologists make against going too fast is that one is unable to adapt to something outside of one's expectations. Actually thinking and not just reacting in a hard-wired way will necessarily slow you down... being careful will also slow you down... but the thinking and the careful analysis is also how the radiologist adds value. Sloppily cranking through cases adds little value... hedging is also fast work and they really hate that. Clinicians can sense a quick and sloppy radiology report, just as you can sense a sloppy H&P.

3) I think the best analogy is a well-written H&P. We all have a good feeling for what it looks and feels like. I don't care about whether the patient has any cats at home or if they wear seatbelts. But I want more relevant information... I want to know I can go to it for the information I need. I need it in a predictable well-organized manner. I would like it to be thoughtfully put together. Someone who cranks out a crap H&P because "why bother, who reads it?" is not doing the patient a service and his or her rationalizations are ultimately self-serving.

Would like to add to some of your other points later, but I have to get out the door. Regarding the bolded, I'm pretty confident that's not true. I don't have the time to find the articles right now, but ordering providers prefer shorter reports. I think there has even been an article pointing out that patients prefer it that way too. I mean, there will always be exceptions, and I would put medical oncologists at the top of the list of providers who want every single lymph node described like a Shakespearean love interest. Overall though, assuming an average cross-section of ordering providers, you're annoying more of them than you're appeasing with a wordy report. However, I think your salient point is about knowing your clinicians. You don't want your report from an abdomen CT for cancer surveillance from the oncologist to look the same as the one for LLQ from the ED, even if the findings are identical.

 

[Gadofosveset]

...

I wrote a response, but deleted it. The issues are complicated and balance is necessary.

My position arises from over-reading pp MRI body exams. All are brief... most are sloppy... too many are sloppy to the point of dangerous. I assume this is a result of time pressure. Clinicians don't like these reports and say so at liver tumor conference.

I used to work with someone who read a huge number of body MRI studies per day. His miss rate was unbelievably high, but frankly he didn't care because the speed made him look good with the boss and made him feel good about himself. He wasn't a bad radiologist, he just didn't care about the "details" anymore. I heard all this rationalizing crap from him, but really patients just didn't get the care they needed when he was reading. What a goober. This is what I'm arguing against.

 

[colbgw02]

...

I wrote a response, but deleted it. The issues are complicated and balance is necessary.

My position arises from over-reading pp MRI body exams. All are brief... most are sloppy... too many are sloppy to the point of dangerous. I assume this is a result of time pressure. Clinicians don't like these reports and say so at liver tumor conference.

I used to work with someone who read a huge number of body MRI studies per day. His miss rate was unbelievably high, but frankly he didn't care because the speed made him look good with the boss and made him feel good about himself. He wasn't a bad radiologist, he just didn't care about the "details" anymore. I heard all this rationalizing crap from him, but really patients just didn't get the care they needed when he was reading. What a goober. This is what I'm arguing against.

I don't think we're that far apart on this issue. When there are abnormalities, they need to be described adequately, to include pertinent positives and negatives. Conversely, normal structures don't need a detailed description of all the different ways they're normal, which is mostly what gets to me. It sounds like a lot of issues you see are related to poorly organized or flat-out incorrect reports, which are separate, albeit related, problems.

 

[fun8stuff]

Slow readers come in a couple of varieties: extremely OCD (extremely verbose and describe every minute detail. Scroll through liver 6 times so as not to miss the TSTC) and/or indecisive ("oh man, should i call this a mild discbulge or a mild-moderate disc bulge... wait, maybe its a moderate protrusion" or spend 10 minutes deciding whether an ACL is torn) or they're just lazy and don't want to work.

I'm part of the lumper camp. I don't think every single borderline enlarged lymph node or probably renal cyst needs to be measured or described in detail. I don't mention most spleunles or bone islands, unless I feel I should based on history and if it has never been described previously (e.g. patient has lymphoma / prostate cancer). These are things that are almost never clinically relevant (as are a lot of things you'll learn during training). Part of your job as a radiologist is to decide what is important for the report.

For example, I don't think there is much value added by saying on the 80 yo trauma CT, "there are multiple round fluid attenuating lesions in the kidneys that are incompletely characterized due to lack of intravenous contrast . The largest on the right is located in the posterior upper pole measuring 5 x 3 x 6 mm in the AP, CC, transverse dimensions (compared to prior on 9/12/2009 where it measured 4 x 4 x 5 mm). Differences in measurement may be due to measuring technique. The largest on the left is....". Instead, I'd say "Multiple subcentimeter cystic lesions in the kidneys bilaterally that appear unchanged compared to the prior exam and are probable renal cysts." It is not that uncommon (at least where I trained) for some radiologists to be completely OCD and have all their reports follow the style of the first example, which takes nearly 10x longer to produce but adds near zero value to the clinician. It's not just how they make their reports either, but also how they approach the exam: they're going feel obligated to link the axial and coronal images on that CT to the one from 5 yrs ago and make direct comparisons in all dimensions scrolling through those kidneys 3-4 times on each one and spending extra time making sure their measurements are dead on.

You see, some people succeeded in undergrad and med school because they were extremely meticulous and hard working. While others in the "fast reader" camp, succeeded because school came natural to them (but they are also likely very hard working). My attendings who were slow because they are OCD (not because they are lazy) were the type of people I'd see in med school who had rewritten their notes 5 times and highlighted everything with 7 different colors and had 1000+ notecards per subject or rotation. Some of these types of people did well (some even very well), but dedicated 10x the time compared to others who did similarly well but dedicated much less time to achieving those results. The slow readers who aren't lazy try and apply that same meticulous mentality to radiology which just is not practical (and often times not valuabe).

 

[vm26]

My attendings who were slow because they are OCD (not because they are lazy) were the type of people I'd see in med school who had rewritten their notes 5 times and highlighted everything with 7 different colors and had 1000+ notecards per subject or rotation. Some of these types of people did well (some even very well), but dedicated 10x the time compared to others who did similarly well but dedicated much less time to achieving those results. The slow readers who aren't lazy try and apply that same meticulous mentality to radiology which just is not practical (and often times not valuabe).

Ironic how once beneficial traits such as being ocd become detrimental

 

[scootad.]

Duplicate

 

[scootad.]

Slow readers come in a couple of varieties: extremely OCD (extremely verbose and describe every minute detail. Scroll through liver 6 times so as not to miss the TSTC) and/or indecisive ("oh man, should i call this a mild discbulge or a mild-moderate disc bulge... wait, maybe its a moderate protrusion" or spend 10 minutes deciding whether an ACL is torn) or they're just lazy and don't want to work.

I'm part of the lumper camp. I don't think every single borderline enlarged lymph node or probably renal cyst needs to be measured or described in detail. I don't mention most spleunles or bone islands, unless I feel I should based on history and if it has never been described previously (e.g. patient has lymphoma / prostate cancer). These are things that are almost never clinically relevant (as are a lot of things you'll learn during training). Part of your job as a radiologist is to decide what is important for the report.

For example, I don't think there is much value added by saying on the 80 yo trauma CT, "there are multiple round fluid attenuating lesions in the kidneys that are incompletely characterized due to lack of intravenous contrast . The largest on the right is located in the posterior upper pole measuring 5 x 3 x 6 mm in the AP, CC, transverse dimensions (compared to prior on 9/12/2009 where it measured 4 x 4 x 5 mm). Differences in measurement may be due to measuring technique. The largest on the left is....". Instead, I'd say "Multiple subcentimeter cystic lesions in the kidneys bilaterally that appear unchanged compared to the prior exam and are probable renal cysts." It is not that uncommon (at least where I trained) for some radiologists to be completely OCD and have all their reports follow the style of the first example, which takes nearly 10x longer to produce but adds near zero value to the clinician. It's not just how they make their reports either, but also how they approach the exam: they're going feel obligated to link the axial and coronal images on that CT to the one from 5 yrs ago and make direct comparisons in all dimensions scrolling through those kidneys 3-4 times on each one and spending extra time making sure their measurements are dead on.

You see, some people succeeded in undergrad and med school because they were extremely meticulous and hard working. While others in the "fast reader" camp, succeeded because school came natural to them (but they are also likely very hard working). My attendings who were slow because they are OCD (not because they are lazy) were the type of people I'd see in med school who had rewritten their notes 5 times and highlighted everything with 7 different colors and had 1000+ notecards per subject or rotation. Some of these types of people did well (some even very well), but dedicated 10x the time compared to others who did similarly well but dedicated much less time to achieving those results. The slow readers who aren't lazy try and apply that same meticulous mentality to radiology which just is not practical (and often times not valuabe).

This post says it all. It's these OCD rads that have zero clinical acumen, lack common sense and can't see the forest for the trees. They simply can't distinguish the important findings from the incidental meaningless ones. They tend to recommend further expensive workups that are unnecessary (ie adrenal MRI for nodules that meet CT criteria for benign adenomas) and handcuff the referrers by not answering the clinical questions and hiding behind radiology jargon. They also are the radiologists paranoid about missing a 2 mm cancer and scared of being sued thereby call every ditzel and TSTC "indeterminate." They are too scared to call a classic liver hemangioma a hemangioma.

It's these same people that can't pull their weight in PP and end up miserable in radiology.

Don't be one of them.

 

[Gadofosveset]

This post says it all. It's these OCD rads that have zero clinical acumen, lack common sense and can't see the forest for the trees....

Somehow in this debate I ended up on the other side of what I fundamentally believe and practice.

There are really two arguments going on here: are you going too slow to be useful? are you going too fast to be useful/safe? The arguments overlap, hence the discussion. I think bringing the discussion out into the open is useful, at least.

Since this is a student/resident site, I suppose I'm urging caution because omitting "unimportant" details is really more of a master move. I overread residents who are moving too fast because they need to "develop speed". When and where does the inexperienced senior resident (occ. lazy senior resident) become the master who omits useless detail? Somewhere, maybe... but it's nebulous. The "omitter" group contains two conflated groups: the true master omitters and the lazy/stupid. Do you have to measure every renal cyst in three dimensions? Of course not, that's insane. Do you have to look for every subsegmental PE? Usually not, but it depends. Do you have to "OCD" examine every tiny branch of the portal vein in a patient with cirrhosis and a LI-RADS 4A+ lesion? Yes.

I think we're basically all on the same side here.

 

[shark2000]

Slow readers come in a couple of varieties: extremely OCD (extremely verbose and describe every minute detail. Scroll through liver 6 times so as not to miss the TSTC) and/or indecisive ("oh man, should i call this a mild discbulge or a mild-moderate disc bulge... wait, maybe its a moderate protrusion" or spend 10 minutes deciding whether an ACL is torn) or they're just lazy and don't want to work.

I'm part of the lumper camp. I don't think every single borderline enlarged lymph node or probably renal cyst needs to be measured or described in detail. I don't mention most spleunles or bone islands, unless I feel I should based on history and if it has never been described previously (e.g. patient has lymphoma / prostate cancer). These are things that are almost never clinically relevant (as are a lot of things you'll learn during training). Part of your job as a radiologist is to decide what is important for the report.

For example, I don't think there is much value added by saying on the 80 yo trauma CT, "there are multiple round fluid attenuating lesions in the kidneys that are incompletely characterized due to lack of intravenous contrast . The largest on the right is located in the posterior upper pole measuring 5 x 3 x 6 mm in the AP, CC, transverse dimensions (compared to prior on 9/12/2009 where it measured 4 x 4 x 5 mm). Differences in measurement may be due to measuring technique. The largest on the left is....". Instead, I'd say "Multiple subcentimeter cystic lesions in the kidneys bilaterally that appear unchanged compared to the prior exam and are probable renal cysts." It is not that uncommon (at least where I trained) for some radiologists to be completely OCD and have all their reports follow the style of the first example, which takes nearly 10x longer to produce but adds near zero value to the clinician. It's not just how they make their reports either, but also how they approach the exam: they're going feel obligated to link the axial and coronal images on that CT to the one from 5 yrs ago and make direct comparisons in all dimensions scrolling through those kidneys 3-4 times on each one and spending extra time making sure their measurements are dead on.

You see, some people succeeded in undergrad and med school because they were extremely meticulous and hard working. While others in the "fast reader" camp, succeeded because school came natural to them (but they are also likely very hard working). My attendings who were slow because they are OCD (not because they are lazy) were the type of people I'd see in med school who had rewritten their notes 5 times and highlighted everything with 7 different colors and had 1000+ notecards per subject or rotation. Some of these types of people did well (some even very well), but dedicated 10x the time compared to others who did similarly well but dedicated much less time to achieving those results. The slow readers who aren't lazy try and apply that same meticulous mentality to radiology which just is not practical (and often times not valuabe).

Well said. Also there are many things that are emphasized in academics, but don't have any clinical importance.

I think attending multiple tumor boards and having close relationship with clinicians help us shape our reports and generate better and more useful reports.

 

[deleted647155]

Is a solution for pp to hire more radiologists? Sure, you'll sacrifice some income but you will have a lower workload, more accurate repirts, less misses, and better work-life balance?

I read that most pp just tpok on a larger workload due to decreasing reimbursement to milk as much money as possible right now?

 

[FranzLO]

I am beginning to despise older generations of physicians and specifically rads now...

 

[shark2000]

Is a solution for pp to hire more radiologists? Sure, you'll sacrifice some income but you will have a lower workload, more accurate repirts, less misses, and better work-life balance?

I read that most pp just tpok on a larger workload due to decreasing reimbursement to milk as much money as possible right now?

Hiring more people does not translate into more accurate reports and less misses.

"Milk as much money as possible" is not a good term to use. pp radiologists simply work the same as other physicians or any other profession. It is like saying that hospitalists or surgeons milk as much money as possible because they can hire more hospitalists or more surgeons to do the job.

Despite all the moan and groan, people in general are satisfied working as a radiologist. Otherwise, they wouldn't work till the age of 70.

When you talk about solution, you imply that there is a problem with the workload. I don't think there is a big problem that needs solution. Everyone in medicine is squeezed and radiology is not an exception.

 

[vm26]

I am beginning to despise older generations of physicians and specifically rads now...

Be nice...these guys are simply trying to put food on the table...

 

[PL198]

Slow readers come in a couple of varieties: extremely OCD (extremely verbose and describe every minute detail. Scroll through liver 6 times so as not to miss the TSTC) and/or indecisive ("oh man, should i call this a mild discbulge or a mild-moderate disc bulge... wait, maybe its a moderate protrusion" or spend 10 minutes deciding whether an ACL is torn) or they're just lazy and don't want to work.

I'm part of the lumper camp. I don't think every single borderline enlarged lymph node or probably renal cyst needs to be measured or described in detail. I don't mention most spleunles or bone islands, unless I feel I should based on history and if it has never been described previously (e.g. patient has lymphoma / prostate cancer). These are things that are almost never clinically relevant (as are a lot of things you'll learn during training). Part of your job as a radiologist is to decide what is important for the report.

For example, I don't think there is much value added by saying on the 80 yo trauma CT, "there are multiple round fluid attenuating lesions in the kidneys that are incompletely characterized due to lack of intravenous contrast . The largest on the right is located in the posterior upper pole measuring 5 x 3 x 6 mm in the AP, CC, transverse dimensions (compared to prior on 9/12/2009 where it measured 4 x 4 x 5 mm). Differences in measurement may be due to measuring technique. The largest on the left is....". Instead, I'd say "Multiple subcentimeter cystic lesions in the kidneys bilaterally that appear unchanged compared to the prior exam and are probable renal cysts." It is not that uncommon (at least where I trained) for some radiologists to be completely OCD and have all their reports follow the style of the first example, which takes nearly 10x longer to produce but adds near zero value to the clinician. It's not just how they make their reports either, but also how they approach the exam: they're going feel obligated to link the axial and coronal images on that CT to the one from 5 yrs ago and make direct comparisons in all dimensions scrolling through those kidneys 3-4 times on each one and spending extra time making sure their measurements are dead on.

You see, some people succeeded in undergrad and med school because they were extremely meticulous and hard working. While others in the "fast reader" camp, succeeded because school came natural to them (but they are also likely very hard working). My attendings who were slow because they are OCD (not because they are lazy) were the type of people I'd see in med school who had rewritten their notes 5 times and highlighted everything with 7 different colors and had 1000+ notecards per subject or rotation. Some of these types of people did well (some even very well), but dedicated 10x the time compared to others who did similarly well but dedicated much less time to achieving those results. The slow readers who aren't lazy try and apply that same meticulous mentality to radiology which just is not practical (and often times not valuabe).

This is exactly what I was thinking as I read this thread . I'm an ms2 so my thoughts were only conceptual but it seemed clearly like the difference between the person who underlines every word in a review book vs the one who sees the forest. There's just that intangible common sense and awareness of the important things at play some people have that others have absolutely 0 of.

This is by far the best thread I've ever seen on sdn

 

[PL198]

What do you guys think about residencies in terms of preparing people. I've read stories where people say the higher ranked academic programs actually prepare you worse for real world radiology