Career questions

[nrosigh]

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Thanks to everyone (f_w in particular) who offers outstanding advice here...

I'm an MS2 interested in "using technology to do things." I'm definitely attracted to radiology, but my two concerns are: 1) Is it isolating to look at films all day? and 2) How do you know that you're good? How do you get feedback on the quality of your reads?

I know it's relatively early in my "career" to settle on a specielty. The fields I'm interested in, however, happen to be competitive, so it would be nice to have some sort of plan before M3 year starts. Here are the pros and cons of some careers I'm "tossing around":

1) Interventional Rads.
Pros: can "do things", some patient management is involved, highly technological, can really make a + difference in pts lives
Cons: turf battles with other specialties, questionable future of field?

2) Interventional Cards.
Pros: same as IR
Cons: would prefer a more universal approach, not just focus on the heart

3) Neurosurgery.
Pros: fascinating
Cons: 100+ hour/wk lifestyle, big risk of being sued, lots of sawing through skulls, lots of trauma, lots of bad outcomes

4) Diagnostic Rads.
Pros: very interesting mix of pathology and technology, constant infusement of new technology
Cons: no patient management, sitting in a dark room all day.

Am I totally off base on any of my pigeonholing here? And thoughts at all would be greatly appreciated.

Thanks in advance!

 

[Docmike2006]

Thanks to everyone (f_w in particular) who offers outstanding advice here...

I'm an MS2 interested in "using technology to do things." I'm definitely attracted to radiology, but my two concerns are: 1) Is it isolating to look at films all day? and 2) How do you know that you're good? How do you get feedback on the quality of your reads?

I know it's relatively early in my "career" to settle on a specielty. The fields I'm interested in, however, happen to be competitive, so it would be nice to have some sort of plan before M3 year starts. Here are the pros and cons of some careers I'm "tossing around":

1) Interventional Rads.
Pros: can "do things", some patient management is involved, highly technological, can really make a + difference in pts lives
Cons: turf battles with other specialties, questionable future of field?

2) Interventional Cards.
Pros: same as IR
Cons: would prefer a more universal approach, not just focus on the heart

3) Neurosurgery.
Pros: fascinating
Cons: 100+ hour/wk lifestyle, big risk of being sued, lots of sawing through skulls, lots of trauma, lots of bad outcomes

4) Diagnostic Rads.
Pros: very interesting mix of pathology and technology, constant infusement of new technology
Cons: no patient management, sitting in a dark room all day.

Am I totally off base on any of my pigeonholing here? And thoughts at all would be greatly appreciated.

Thanks in advance!

Consider law🙂

On a serious note, rads is great for technology but it does have drawbacks. Have you considered pharmaceutical/medical devices industry? They do employ physicians.

 

[nrosigh]

Consider law🙂

On a serious note, rads is great for technology but it does have drawbacks. Have you considered pharmaceutical/medical devices industry? They do employ physicians.

Well, I certainly haven't considered that yet, but I may have a different opinion after wandering the wards next year (in a few weeks actually!).

At this point I definitely want to be some sort of practicing physician. But Rads/IM/Neurosurgery all have drastically different residencies....

I have a feeling though, that whatever I do I'll have a good time at...

What would you say the drawbacks are? Nice site by the way, interesting cases there...

 

[hans19]

Most people pop into the forum and ask 'how much does [insert specialty] make? What does a [insert specialty] do?' when the answers to these can easily be googled.

It's refreshing to see that you've at least looked into the fields of your interest and its clear you've done a little research on your part. 👍
Now you have directed questions, which I'll happily answer. 😀

Your generalizations of each field are more or less accurate.
Let me give you my take on the various specialties, from the perspective of radiology/IR

Radiology is an immensely rewarding specialty for the reasons, you've already mentioned. The nature of the field entails using new technologies and improvements in existing technologies for medical diagnosis.

IMO, the interesting part of internal medicine of the old days was the detective work- using the physical examination and the history to arrive upon a diagnosis. Of course this was before the days of advanced radiology and immunologically based labs, but the days of detective work in IM (IMO) are largely diminished. Now you have to worry about paper work, HMOs, social issues, which are peripheral to the art and science of medicine (again all IMO).

Now-a-days the detective work is done in radiology. You look at the organs, in effect you are literally performing a visual physical exam, making the findings and arriving on a differential- thats fun. Its really cool when you make a diagnosis, sometimes an improbable one, and you're right about it. The other day when I was on call, we diagnosed a jejunal diverticulum (pretty rare) which had perforated, and looked like a loop of colon filled with stool (to the untrained eye). We notified the surgeons, and they were perhaps a little skeptical. One of the surgeons stopped me in the hallway a few days later to tell me they ended up taking the patient to the OR and we were dead on about the dx!

Contrary to popular belief you DO interact with people. Those people are other physicians-- your peers. Instead of explaining to a patient why they need to lose weight, stop smoking, and be compliant with their meds, as a radiologist talk to your peers about the things that interested you to go to medical school, in the first place. You interact with all specialties: internists, pediatricians, general surgeons, specialty surgeons alike. Your knowledge base means you can comfortably talk shop with virtually any specialist.


As far as IR goes, there will always be a need for interventionalists, but the role of IRs are changing. The majority of endovascular work is being coopted by vascular surgeons and cardiologists. The reasons are primarily because theses specialists see the patient first and thus get 'dibs' on performing procedures on those patients. However, new image guided procedures are coming down the pike and IRs get the first crack at them. Furthermore IRs are evolving into clinicians. In order to keep turf and even win back lost turf, IRs are having their own clinics and see patients pre-op and seeing them for follow up.

Of all the specialists you named, cardiologists seem to be the most aggressive. From radiology they learned echo, cardiac cath (nearly putting cardiovascular surgery out of business) and are trying to learn noninvasive imaging of the heart (nuclear medicine, CT and MR). Furthermore they are marketing themselves as 'cardiovascular' doctors and are trying to treat peripheral vascular disease, stepping on the toes of vascular surgeons and IRs. As their numbers are greatest, they are best positioned to win the endovascular turf war. (As far as IR goes, though endovascular procedures were pioneered by IRs and used to be a large component of IR, the field is so much more than endovascular work. But that is something you can google.)

Regarding neurosurgery--
Lets say you like porterhouse steaks. You could easily finish a 20oz, but man what if you had to eat steak non stop 16 hours a day, and had it for a meal 4x a day, every day... get my drift? Its the same for a neurosurgery residency. Even if you liked neurosurgery, doing it 24/7/365 to the exclusion of a personal life and sleep, gets old really fast.

When they get out, except for the occasional trauma burr hole, most private practice neurosurgeons dont do intracranial work. They mostly do lucrative spine surgeries for back pain with quasi regular hours. This can be monotonous and a certain subset of this population are needy chronic pain/pain med abusing types. Furthermore, as a neurosurgeon you will have to get used to getting sued, which I imagine would be a total hassle, in addition to paying astronomical malpractice premiums. You are right in that bad outcomes are not uncommon in neurosurgery. If you can sleep at night knowing that your actions may have directly (or indirectly) made a vegetable out of a[n] (at least partially functioning) human being, than you have yourself a great paying job for life. Don't get me wrong, neurosurgery is cool as hell to read about, but the actual practice of it is not for me.

My 2 cents.

 

[f_w]

I'm an MS2 interested in "using technology to do things.

Young man, radiology is the right place for you !

2) How do you know that you're good?

You don't get your a@@ sued. More seriously, in rads, you constantly have to 'audit' your own work. In one area (mammo), you are actually legally required to do so. If you said its cancer, your QA tech will tell you the result of the biopsy and you will learn whether you where right. In other areas, there is no formal requirement to audit your work. But it is good practice to check on the hospitals electronic medical record whether that appendicitis you callled on a CT turned out to be hot.

How do you get feedback on the quality of your reads?

Your surgeons will yell at you if you are wrong. You will know whether you are good if your subspecialists come and bring studies to review and ask you questions about further diagnostic strategies (if you notice that people avoid asking your opinion, you are either a grouch or your opinion is deemed useless).

I know it's relatively early in my "career" to settle on a specielty.

It is certainly too early to settle on a specialty, thinking about it is a good idea.

1) Interventional Rads.
Pros: can "do things", some patient management is involved, highly technological, can really make a + difference in pts lives
Cons: turf battles with other specialties, questionable future of field?

Except for the 'questionable future of field' you have everything right here. There is no question in my mind that IR has a good future, the question remains as to what the scope of practice and the model of practice will be. I believe it will be more of a clinically oriented service spending less time in the procedure suite doing low-brain/decent money kind of work and more time seing patients in your office. It will also see more use of midlevels (to do the low-brain/decent money kind of work). The income won't be quite what people doing procedures full-time are used to, but it will be a very viable type of practice.

2) Interventional Cards.
Pros: same as IR
Cons: would prefer a more universal approach, not just focus on the heart

Actually, a good number of interventional cards ar focussing on other areas of the vascular system. But you are right, we call them 2-vessel angiographers. Many are very pump centered. If it doesn't affect the heart, they don't care. Highly skilled technicians who have lost sight of the greater picture.
Main drawback of interventional cards is the fact that you have to do an IM residency. That is just 3 years of unadulterated horror, deformed personalities, undeciciveness and bad smells. If you could interventional cards without the IM part, it would be far more attractive.

3) Neurosurgery.
Pros: fascinating
Cons: 100+ hour/wk lifestyle, big risk of being sued, lots of sawing through skulls, lots of trauma, lots of bad outcomes

Its only fascinating until you have seen the 100th back pain patient that you CAN operate on but you know that in all likelihood you won't help him a whole lot. Everyone thinks about the big time tumor OPs and forgets about the fact that just like any other field it comes with lots of routine stuff.
As for cons. Depending on your practice setting, you might not see any trauma at all. If you don't do it during the day, you are not obliged to take care of it at night. There are enough community hospital neurosurgeons who will just see that bashed skull in the ER and recommend transfer to the trauma center.

4) Diagnostic Rads.
Pros: very interesting mix of pathology and technology, constant infusement of new technology
Cons: no patient management, sitting in a dark room all day.

Sitting in a dark room all day is a key perk of diagnostic radiology, so is 'not talking to patients'.
If you like sitting in your clinic and listen to the patients stories about that vagitch that started right after Eisenhower became president, go into FP.
Yes you see only few patients in person every day, but you impact the care of many. Your human interaction is more likely with your physician colleagues, in that sense you are similar to pathologists who (except for the ones doing fine needle aspirations) don't deal with patients.

Am I totally off base on any of my pigeonholing here?

I think you are pretty close to the mark in most of your little blurbs. I recommend to keep an open mind until the second half of 3rd year. Shining during a surgery clerkship will help you to get into rads

 

[nrosigh]

My 2 cents.

Wow, what a great response, thank you for taking the time to write it!

Radiology is looking more and more like the answer. I really like how you describe the interactions between physicians, and I think that I'd like dealing with different specialists. Another bonus of doing a normal Rads residency is that there's always the option of doing an IR fellowship after the 1+4.

Good analogy about neurosurgery. I've read a handful of popular books: "when the air hits your brain," "first do no harm," "the healing blade," "walking out on the boys," which are all very enjoyable ways to spend an afternoon, but the actual down and dirty of not spending any time with my family (or my pillow!) is not appealing.

I know this sounds anecdotal because of my incomplete memory, but I read it a few months ago: A chief of neurosurgery quit the field altogether to start a Rads residency as a first year resident. That pretty much sums it up for me.

 

[nrosigh]

Young man, radiology is the right place for you !

Thanks f_w: I've read a bunch of your other posts and have always been impressed with how much you know, and how willing you are to share with all the anonymous randoms out there (like me).

It's funny, because whenever anyone I know asks me what field I'm interested, as soon as I say, "I'm not sure, but I think I'll really like radiology," they say "I can totally see you doing that!!" Which is kind of funny, because you said the same thing and you don't know me from a glory-hole in the wall....

I did not know that about Mammo. That's good that you get feedback on how good your reads are. NyTimes just has an interesting article called "a star is born": I can't paste the link in because the new firefox seems to have a bug in it, but you can find the article from the front page if you scroll down to the most popular emailed articles sidebar. It talks about how surgeons are the only medical specialty that "get better" with experience since they get instant feedback.

It's also encouraging to hear that IR has a bright future.

Thanks again for the really helpful and detailed response!

 

[f_w]

I know this sounds anecdotal because of my incomplete memory, but I read it a few months ago: A chief of neurosurgery quit the field altogether to start a Rads residency as a first year resident. That pretty much sums it up for me.

Somewhere on Long Island if my memory doesn't fool me.

NyTimes just has an interesting article called "a star is born":

The medical editor/writers for the NYT traditionally have no f@)(+%$ clue about their subject matter.

 

[KB_Xiii]

hans19:
wonderful post.. I rarely read long posts, but in this case it was worth it 🙂

nrosigh:
You pretty much mentioned all the specialties I was interested in, except I had pathology on the list too..
I ended up choosing Diag. rads for the following reasons:
1. You like the specialty.
2. You like technology.
3. You can still upgrade it to IR, if patient contact was an issue.
4. You specialize right away by doing Diag. rads, unlike I.Cards where you have to go through IM first (to me that wasn't an option!)
5. You mentioned I.Cards was "just the heart", well neurosurg. is just "neuro". Diagnostic rads is broad, you specialize practice wise, but not system wise (at least in the beginning)..
6. If you fell in love with a certain modality, you can specialize in it (CT, MRI, mammo..)
7. If you fell in love with a certain system, you can specialize in it (neuro, gyne, vasc...)

I personally couldn't find any drawback in Diag. rads. not a single one!
But then we're biased, you should ask the same Q under cards and neurosurg 😉

 

[Taurus]

hans19 and f_w are great!

I've learned so much from them about rads. I like rads more and more each day.

To the OP, I wouldn't fret about sitting in the dark looking at film. I used to work in IT where it's similar. You can sit back, drink your coffee, do your work, and collaborate with your coworkers. Or you can recite the same medicolegal spiel to your 25th patient of the day or be going on hour 6 of surgery.

 

[Taurus]

I have a follow-up question. How often do rads get sued and what is the malpractice premiums like? I heard that rads are initially included on most lawsuits (since everything is imaged these days) but get dropped from the lawsuit once the lawyers figure where the liability is at. I'm assuming diagnostic rads. The answer probably differs according to subspecialty.

 

[IheartCaffeine]

Sitting in a dark room all day is a key perk of diagnostic radiology, so is 'not talking to patients'.
If you like sitting in your clinic and listen to the patients stories about that vagitch that started right after Eisenhower became president, go into FP.
Yes you see only few patients in person every day, but you impact the care of many. Your human interaction is more likely with your physician colleagues, in that sense you are similar to pathologists who (except for the ones doing fine needle aspirations) don't deal with patients.

To the OP, I wouldn't fret about sitting in the dark looking at film. I used to work in IT where it's similar. You can sit back, drink your coffee, do your work, and collaborate with your coworkers. Or you can recite the same medicolegal spiel to your 25th patient of the day or be going on hour 6 of surgery.

I'm only an M1, but I totally agree that the dark room thing is a perk, not a drawback. The image Taurus created, with the coffee (and I'll throw a comfortable, high back leather chair in there), sounds far more appealing than the alternatives. (I'm thinking that if you already hate patients as an M1, then rads might be worth taking a very close look at). Also, I really like the fact that you collaborate far more with physicians than patients. I hate having to dumb down my opinions about things when talking to lay people, I can't stand it. Not just with science stuff, but the others things I'm in to. Computers, politics, technology, cars, etc. It's just takes all the fun out of it if you have to put sophisticated concepts into lay terms. And if someone feels lazy for being in a chair for the majority of the workday, Rads is the specialty that is most conducive to living a healthy and active lifestyle outside of the office.

 

[Carb Addict]

...you have to do an IM residency. That is just 3 years of unadulterated horror, deformed personalities...

OH! Do elaborate, my good man!

(I personally find personality disorders to be interesting psychopathology...I'm sure you were getting at something else, though. lol)

 

[f_w]

I have a follow-up question. How often do rads get sued and what is the malpractice premiums like?

Way to f-ing often. 60% of liability in rads comes from one study: Mammography. Scenario is the same: 45 year old women has annual screening mammo. 11 months later she presents with metastatic breast ca. Bribed plaintiff ***** expert witness (a surgeon who has lost his license over incompetence) testifies that the 'mammagram' from 1 year ago clearly shows a 'shadow' --> 12 village idiots in the jury award $5mio to the poor suffering mother of 3 who will die to this cruel disregard of the evil radiologist.

On average, you get sued twice in your career. But there is clearly a wide distribution. There are very good people in places like IL or AL who get sued twice a year and others who suck but practice in rural WI who get through a 40 year career without ever being named.

As for the malpractice premiums: Nobody can give you a number for that as it has a high regional variability. But just for ballpark numbers: 4 years or so ago, I looked up the 'occurence' premium for various specialties in the state of NY (excluding the counties of NY, Kings, Queens, Richmond, Rockland, Westchester, Nassau and Suffolk). For an internist it was something like 9k per year. For a diagnostic radiologist it was about 30+k. An obstretician 110k and a neurosurgeon 140k. So you get the basic ratios, somewhere in the same range as a general surgeon who doesn't do major vascular. The problem is that rates for rads are rising faster than the average (2 years ago rates in MA went up by 32% in one year).

(I'm thinking that if you already hate patients as an M1, then rads might be worth taking a very close look at)

If you hate patients as an M1, you should probably pursue another career before you invest more money into this dead end. I don't hate patients, and I actually like talking to them. I just don't like talking to them all day.

 

[Leukocyte]

Dear OP

Did you do a Radiology elective? No matter how many books you read about a speciality, there is nothing like hands on experience.

You should do an elective in each of the specialities you are considering, then decide.

Good Luck.

 

[shorrin]

hans19 and f_w are great!

I've learned so much from them about rads. I like rads more and more each day.

To the OP, I wouldn't fret about sitting in the dark looking at film. I used to work in IT where it's similar. You can sit back, drink your coffee, do your work, and collaborate with your coworkers. Or you can recite the same medicolegal spiel to your 25th patient of the day or be going on hour 6 of surgery.

ditto that. I used to spend hours and hours /day in the dark manipulating pics in photoshop for advertising campaigns. It was akin to meditation. The only thing I will miss is getting in around 10am 😉.