Advice from an attending radiologist

[PL198]

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Any thoughts on how to buck this trend?

will never happen. physicians are too passive and financially illiterate on the whole to take necessary action to reverse.

 

[meister]

No CEO is worth 20-30 pediatricians, what a laughable suggestion. Executive pay inflation is just metastasizing from finance.

 

[PL198]

No CEO is worth 20-30 pediatricians, what a laughable suggestion. Executive pay inflation is just metastasizing from finance.

that's just jealousy talking. you can't honestly tell me you don't think a CEO of a multi-billion dollar company isn't worth 6 mil/year? these aren't avg joes.

 

[RadsonRads]

that's just jealousy talking. you can't honestly tell me you don't think a CEO of a multi-billion dollar company isn't worth 6 mil/year? these aren't avg joes.

Agree with every bit of this. People who don't think they are worth their salary haven't been around a real financial CEO or the like, on a day-to-day basis. I have, and these guys are literally unstoppable. They never take a day off and work 24/7. It really is remarkable.

 

[bronx43]

that's just jealousy talking. you can't honestly tell me you don't think a CEO of a multi-billion dollar company isn't worth 6 mil/year? these aren't avg joes.

So, it depends, right? It's about value added, and not necessarily dollars "earned." In a completely free market, I would venture that everyone "deserves" their salary, since they (in theory) would be adding commensurate value as dictated by said market. Value is what another individual would pay for a good or a service. A pediatrician would be subject to the same market forces as a CEO would, and despite some objections here, I would also say that the average pediatrician wouldn't fetch more than 160-170k in a free market (and neither would most physicians, but that's a topic for later discussion.) In comparison, a CEO of a multi-billion company that shows certain earnings numbers would absolutely be worth 7 figures if the board thinks that is the amount of money needed to retain such level of talent in order to maintain growth of the company. I don't think anyone would lament Steve Jobs getting 9-10 figures or Larry Page being worth billions.
The discussion here is about hospital CEOs, and whether or not they are worth millions. It's hard to say, as we stated before, the corporatization of health care did not increase productivity or efficiency. If anything, inefficiencies were magnified, as large entities have higher maintenance and management cost than smaller individual units of operation. Whatever value-add these CEOs have is entirely within the context of a centrally planned and manipulated market. Would these hospitals really be all that profitable if everything was out of pocket and there was no reimbursement numbers being pulled out of thin air by the CMS? Would they be able to dominate the market to this extent if independent practitioners can undercut them with lean and high value practices, hence offering greater value to suddenly price conscious consumers? Can they survive competition with each other if the astronomically high regulatory costs were suddenly decreased as to increase formation of new hospitals?
Again, I hate these sweeping and superficial generalizations about CEOs making this or that - you really need to dig deep and think about why things are the way they are, and whether or not they are sustainable or (dare I say?) fair...

 

[bronx43]

Agree with every bit of this. People who don't think they are worth their salary haven't been around a real financial CEO or the like, on a day-to-day basis. I have, and these guys are literally unstoppable. They never take a day off and work 24/7. It really is remarkable.

I know high finance (hedge fund, PE, Goldman) guys, and guys high up in the corporate ladder (not yet C level, however). Yes, they work very hard. Some work harder than the hardest working resident. And if they generate earnings for their company/fund/firm, then they are absolutely right in getting a big cut. The issue I think some people have is when this becomes de-coupled, and you have people in high finance getting huge bonuses while their banks are insolvent based on the strategies they instituted. Tell me why is it that Bears Sterns or Merrill Lynch MDs can get 7-8 figure bonuses while they accept trillions in taxpayer money to recapitalize their debt while selling to other slightly less insolvent banks also taking bailout money.

 

[PL198]

So, it depends, right? It's about value added, and not necessarily dollars "earned." In a completely free market, I would venture that everyone "deserves" their salary, since they (in theory) would be adding commensurate value as dictated by said market. Value is what another individual would pay for a good or a service. A pediatrician would be subject to the same market forces as a CEO would, and despite some objections here, I would also say that the average pediatrician wouldn't fetch more than 160-170k in a free market (and neither would most physicians, but that's a topic for later discussion.) In comparison, a CEO of a multi-billion company that shows certain earnings numbers would absolutely be worth 7 figures if the board thinks that is the amount of money needed to retain such level of talent in order to maintain growth of the company. I don't think anyone would lament Steve Jobs getting 9-10 figures or Larry Page being worth billions.
The discussion here is about hospital CEOs, and whether or not they are worth millions. It's hard to say, as we stated before, the corporatization of health care did not increase productivity or efficiency. If anything, inefficiencies were magnified, as large entities have higher maintenance and management cost than smaller individual units of operation. Whatever value-add these CEOs have is entirely within the context of a centrally planned and manipulated market. Would these hospitals really be all that profitable if everything was out of pocket and there was no reimbursement numbers being pulled out of thin air by the CMS? Would they be able to dominate the market to this extent if independent practitioners can undercut them with lean and high value practices, hence offering greater value to suddenly price conscious consumers? Can they survive competition with each other if the astronomically high regulatory costs were suddenly decreased as to increase formation of new hospitals?
Again, I hate these sweeping and superficial generalizations about CEOs making this or that - you really need to dig deep and think about why things are the way they are, and whether or not they are sustainable or (dare I say?) fair...

None of that is ever going to change. For the most part, physicians don't want anything to do with politics or fighting to hold their ground (hence getting killed in literally every battle of policy, ACA, mid-levels, etc etc, they're just perennial losers from a national policy perspective). Avg doc just wants to clock in, do their work and get their check, which is why hospitals are able to take everything over. The docs just dont care enough to do what is necessary for the system to not get steamrolled. So it will. That's what you get when you have a culture that emphasizes memorizing basic science textbooks and humanities and neglecting absolutely everything else.

I agree with what you're saying, I'm just also saying that it's pretty much a hopeless fight in terms of the population wide level.

 

[shark2000]

None of that is ever going to change. For the most part, physicians don't want anything to do with politics or fighting to hold their ground (hence getting killed in literally every battle of policy, ACA, mid-levels, etc etc, they're just perennial losers from a national policy perspective). Avg doc just wants to clock in, do their work and get their check, which is why hospitals are able to take everything over. The docs just dont care enough to do what is necessary for the system to not get steamrolled. So it will. That's what you get when you have a culture that emphasizes memorizing basic science textbooks and humanities and neglecting absolutely everything else.

I agree with what you're saying, I'm just also saying that it's pretty much a hopeless fight in terms of the population wide level.

It is definitely a hopeless battle because one side of the battle is much better at fighting than the other side AND because the game is not fair. The rules of the game have been changed in favor of the first group.

Average doctor wants to come in, work and leave. That is true. Once you don't protect your asset, it will be gone.

 

[bronx43]

None of that is ever going to change. For the most part, physicians don't want anything to do with politics or fighting to hold their ground (hence getting killed in literally every battle of policy, ACA, mid-levels, etc etc, they're just perennial losers from a national policy perspective). Avg doc just wants to clock in, do their work and get their check, which is why hospitals are able to take everything over. The docs just dont care enough to do what is necessary for the system to not get steamrolled. So it will. That's what you get when you have a culture that emphasizes memorizing basic science textbooks and humanities and neglecting absolutely everything else.

I agree with what you're saying, I'm just also saying that it's pretty much a hopeless fight in terms of the population wide level.

Oh, I totally agree. Physicians are in general some of the most risk adverse and passive people I've ever met. An opportunity can hit them in the face and they wouldn't recognize it.

However, that isn't to say that all are like this or that there wouldn't be independent practitioners in the right setting. The problem nowadays is that clocking in and out provides about the same income as starting and running your own practice - all due to low "non-facility" reimbursements. If pay is the same, what's the point of worrying about rent, staffing, billing, supplies, marketing, etc, when you can just go to work and go home?

 

[RAD-GT]

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.

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.

I am coming a little late to this discussion, but am very grateful for the valuable time the practicing Radiologists have given to share their experience.

I had a fairly academic training and have been in private practice for five years now and just recently changed practices. Previously I would read 120-140 studies per day, the usual mix of modalities and procedures. I would however stretch the day out for 10-12 hours and be truly exhausted at the end of it. At my new practice I really need to do the same amount in 8-9 hours. I would at this point consider myself average to slow.

Whereas many others have organically become faster, that hasn't happened for me. What I really hope to learn is of any practical exercises that people have used to become faster with effort. At this point I have some experience and confidence in my readings. What I need is to improve efficiency.

Many useful general observations have been made in the course of this discussion which I have found very applicable. I would really appreciate insight into specific exercises and mental practices or even lifestyle choices that people have used to achieve improving their efficiency. (using a timer per study, letting go of formatting errors in reports, organizing the worklist in a certain way, living closer to work ie whatever works).

 

[scootad.]

RAD-GT: I'm a radiologist in private practice since 2011. I also read 120+ studies/day. I'm consider myself fast and I'm always out by 5 pm. Things I do to get things moving...I keep my reports short and to the point. My impressions are limited to the top 3-4 things that are clinically relevant. If there's only 1 positive finding, that becomes the only item in the impression. If it's a negative study except for something irrelevant (like small renal cysts or liver granulomas) I only state "No acute abdominal pathology" in my impression. My x ray reports are only 3-4 sentences long. I disregard phleboliths on KUB. I time myself on CTs and MRs and never allow myself to spend more than 15 minutes on any 1 study.

Things I see slower radiologists do that I recommend avoiding include having 5-10 item impressions with pertinent negatives (like 1- no meniscal tear 2- no ACL tear 3 - no occult fracture etc.) or listing things like cysts and granulomas in their impressions.

It's also important to use as few words as possible to describe pathology and hone in on the actual diagnosis not the secondary findings.

 

[TheBoss88]

..

 

[tco]

RAD-GT: I'm a radiologist in private practice since 2011. I also read 120+ studies/day. I'm consider myself fast and I'm always out by 5 pm. Things I do to get things moving...I keep my reports short and to the point. My impressions are limited to the top 3-4 things that are clinically relevant. If there's only 1 positive finding, that becomes the only item in the impression. If it's a negative study except for something irrelevant (like small renal cysts or liver granulomas) I only state "No acute abdominal pathology" in my impression. My x ray reports are only 3-4 sentences long. I disregard phleboliths on KUB. I time myself on CTs and MRs and never allow myself to spend more than 15 minutes on any 1 study.

Things I see slower radiologists do that I recommend avoiding include having 5-10 item impressions with pertinent negatives (like 1- no meniscal tear 2- no ACL tear 3 - no occult fracture etc.) or listing things like cysts and granulomas in their impressions.

It's also important to use as few words as possible to describe pathology and hone in on the actual diagnosis not the secondary findings.

I feel like this is what we're being taught at my program. Not all programs are like that, apparently?

 

[Gadofosveset]

I feel like this is what we're being taught at my program. Not all programs are like that, apparently?

You should be taught to look thoroughly through each exam and comment on pertinent negatives, to reinforce search pattern. More overcommenting than undercommenting as a resident is ok. Dropping things from the report and impression is a more advanced move, for fellows and beyond.

Residents do not screw up by overcommenting. You can transition to more streamlined reports as you gain experience, but anyone who wants a resident (esp. junior resident) to burn through cases with minimal dictations is not interested in their learning.

 

[tco]

You should be taught to look thoroughly through each exam and comment on pertinent negatives, to reinforce search pattern. More overcommenting than undercommenting as a resident is ok. Dropping things from the report and impression is a more advanced move, for fellows and beyond.

Residents do not screw up by overcommenting. You can transition to more streamlined reports as you gain experience, but anyone who wants a resident (esp. junior resident) to burn through cases with minimal dictations is not interested in their learning.

If a cyst/granuloma is listed in the findings, it means it wasn't missed. It doesn't need to be in the impression. I will include things like, "Right superior pole simple renal cyst is Bosniak 1 and requires no further evaluation unless clinically indicated." if there aren't numerous other findings of importance.

I haven't had complaints from attendings yet, or bad evaluations, so I'm assuming I'm doing okay.

 

[shark2000]

If a cyst/granuloma is listed in the findings, it means it wasn't missed. It doesn't need to be in the impression. I will include things like, "Right superior pole simple renal cyst is Bosniak 1 and requires no further evaluation unless clinically indicated." if there aren't numerous other findings of importance.

I haven't had complaints from attendings yet, or bad evaluations, so I'm assuming I'm doing okay.

This is a killer. Just say it is a simple cyst and burry it in the report.

"Unless clinically indicated" is overused by some radiologists and at times is nonsense. Could you please explain what further evaluation is required for a simple cyst in what clinical situation/indication? It doesn't make sense to me. What if a family doctor calls you and asks you what do you mean by this sentence?

 

[Gadofosveset]

If a cyst/granuloma is listed in the findings, it means it wasn't missed. It doesn't need to be in the impression. I will include things like, "Right superior pole simple renal cyst is Bosniak 1 and requires no further evaluation unless clinically indicated." if there aren't numerous other findings of importance.

I haven't had complaints from attendings yet, or bad evaluations, so I'm assuming I'm doing okay.

It would be rare for me to put a simple cyst or a granuloma in the impression.

I'm not talking about pointless verbiage. I'm talking about residents who want to be known as the fastest resident, write impressions like "Unremarkable abdomen and pelvis", and then miss the colon mass because "I never look at the colon because it's all artifactual." This kind of attitude needs to be smashed out of a resident because it will only get worse and because it will eventually kill someone.

Short, efficient reports are the goal, just like short, efficient surgeries. But that's a reward of experience; one can't just slash through things as a beginner.

 

[Gadofosveset]

To my mind, there's a normal training spectrum:

1) inaccurate, slow ---> beginner or non-radiologist
2) accurate, slow ---> more advanced trainee
3) accurate, fast ---> master

x) inaccurate, fast --> unacceptable.
I think this comes from jumping from 1 --> 3.

You can gain a lot of speed by paring out neurotic verbiage ("clinically correlate").
Accuracy is both high sensitivity and high specificity. If you're gaining speed as a trainee by not mentioning findings on the study (high specificity), be vigilant about why you're doing it, otherwise it's a short slip to just walking over findings (low sensitivity).

 

[shark2000]

It would be rare for me to put a simple cyst or a granuloma in the impression.

I'm not talking about pointless verbiage. I'm talking about residents who want to be known as the fastest resident, write impressions like "Unremarkable abdomen and pelvis", and then miss the colon mass because "I never look at the colon because it's all artifactual." This kind of attitude needs to be smashed out of a resident because it will only get worse and because it will eventually kill someone.

Short, efficient reports are the goal, just like short, efficient surgeries. But that's a reward of experience; one can't just slash through things as a beginner.

Agree.
And I have seen people who get focused on unnecessary details, miss big things more often.

 

[tco]

This is a killer. Just say it is a simple cyst and burry it in the report.

"Unless clinically indicated" is overused by some radiologists and at times is nonsense. Could you please explain what further evaluation is required for a simple cyst in what clinical situation/indication? It doesn't make sense to me. What if a family doctor calls you and asks you what do you mean by this sentence?

Yeah, I'm not going to put in a report that it requires no further evaluation PERIOD. If that guy develops RCC and starts peeing blood with the world's most incompetent PCP, who are they going to sue? However, there were times during my prelim year that I would read about an incidental finding and we would stew about what to do about it, when, after a phone call to the radiologist, it was "Oh, nothing." Your job is to be helpful to them if you're going to mention something, which, as some new trainees might not know (like I didn't), includes follow up imaging exams (or to tell them that they don't need any more exams). If I'm called about it, I'm going to tell them to get further imaging as they deem fit with normal clinical judgement (hematuria, etc). They understand CYOA medicine...They do it all the time.

 

[shark2000]

Yeah, I'm not going to put in a report that it requires no further evaluation PERIOD. If that guy develops RCC and starts peeing blood with the world's most incompetent PCP, who are they going to sue? However, there were times during my prelim year that I would read about an incidental finding and we would stew about what to do about it, when, after a phone call to the radiologist, it was "Oh, nothing." Your job is to be helpful to them if you're going to mention something, which, as some new trainees might not know (like I didn't), includes follow up imaging exams (or to tell them that they don't need any more exams). If I'm called about it, I'm going to tell them to get further imaging as they deem fit with normal clinical judgement (hematuria, etc). They understand CYOA medicine...They do it all the time.

Your argument is nonsense to me. If your job is to be helpful to people, just say that is is a simple cyst and move on. Every physician should know that a simple renal cyst does not need followup. If they don't know they should google it or if you think still they might not know, then put in your report that a simple renal cyst does not need a follow up. Your report makes more confusion.

Nobody can sue you if you say a simple renal cyst or a stable pulmonary nodule does not need follow up. People do it all the time in mammo when they find a simple cyst. What if the patient develops cancer later? Your logic is nonsense to me. If it is a simple cyst, it does not need follow up. PERIOD.

If you are really afraid of getting sued, quit radiology. I have seen a few radiologists who recommend follow up for almost everything. Some radiology reports are pretty much useless and is like this: "I don't see a cancer but a cancer or a serious pathology can not be excluded."

"If clinically indicated" has its own appropriate uses, but as I mentioned is overused esp by radiologist who don't know what to do or don't know what is going on. "This is an ovarian follicle, but follow up US is recommended if clinically indicated. "

You didn't explain to me what clinical scenario necessities follow up for a simple renal cyst. Let's say I am the most incompetent PCP and call you "Hey, you mentioned that the cyst is simple but further evaluation should be done if clinically indicated. What are the indications?" If the patient has hematuria, it is the follow up of the hematuria and not the cyst. Don't mix things.

 

[scootad.]

I agree with shark2000 100%. I've seen first hand what kind of crappy reports radiologists paranoid of getting sued are capable of creating. Reports that help nobody. They wind up getting phone calls from confused referrers who stop sending you patients as they lose all confidence in your skills if you recommend followup for everything under the sun. Ultimately, they don't even serve their purpose in protecting against a lawsuit.

Most lawsuits are frivolous and almost randomly name everyone on the patient's chart initially regardless of what their report said or didn't say. Then as the lawyers go through the case, names start getting dropped from the suit, as they realize they have no case against you. It has nothing to do with whether or not you recommended followup for that cyst in a patient who ends up getting cancer later for a completely unrelated reason.

 

[tco]

Your argument is nonsense to me. If your job is to be helpful to people, just say that is is a simple cyst and move on. Every physician should know that a simple renal cyst does not need followup. If they don't know they should google it or if you think still they might not know, then put in your report that a simple renal cyst does not need a follow up. Your report makes more confusion.

Nobody can sue you if you say a simple renal cyst or a stable pulmonary nodule does not need follow up. People do it all the time in mammo when they find a simple cyst. What if the patient develops cancer later? Your logic is nonsense to me. If it is a simple cyst, it does not need follow up. PERIOD.

If you are really afraid of getting sued, quit radiology. I have seen a few radiologists who recommend follow up for almost everything. Some radiology reports are pretty much useless and is like this: "I don't see a cancer but a cancer or a serious pathology can not be excluded."

"If clinically indicated" has its own appropriate uses, but as I mentioned is overused esp by radiologist who don't know what to do or don't know what is going on. "This is an ovarian follicle, but follow up US is recommended if clinically indicated. "

You didn't explain to me what clinical scenario necessities follow up for a simple renal cyst. Let's say I am the most incompetent PCP and call you "Hey, you mentioned that the cyst is simple but further evaluation should be done if clinically indicated. What are the indications?" If the patient has hematuria, it is the follow up of the hematuria and not the cyst. Don't mix things.

I agree with shark2000 100%. I've seen first hand what kind of crappy reports radiologists paranoid of getting sued are capable of creating. Reports that help nobody. They wind up getting phone calls from confused referrers who stop sending you patients as they lose all confidence in your skills if you recommend followup for everything under the sun. Ultimately, they don't even serve their purpose in protecting against a lawsuit.

Most lawsuits are frivolous and almost randomly name everyone on the patient's chart initially regardless of what their report said or didn't say. Then as the lawyers go through the case, names start getting dropped from the suit, as they realize they have no case against you. It has nothing to do with whether or not you recommended followup for that cyst in a patient who ends up getting cancer later for a completely unrelated reason.

Fair enough. You guys have more experience than I do. I'll yield to your knowledge.

I will say that it very much depends on the department you're training in. I'm coming down hard on things this month at MD Anderson. They. Have. No. Fear...Of anything.