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Is Diagnostic Radiology Boring? Fulfilling? Fun?

Discussion in 'Radiology' started by Hedwig, Dec 26, 2001.

  1. Hedwig

    Hedwig Senior Member

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    Hi,

    I'm currently a post-bacc premed student. I have a ton of clinical experience, and out of everything I've seen, I'm most interested in and enamored with diagnostic radiology. I recently had to have a liver / gallbladder ultrasound, an ECG, and a brain MRI—I'm hooked! This is honestly the most amazing stuff I've ever seen in my entire life.

    My question is, does a diagnostic radiologist's career involve simply reading scans and making diagnoses based on these all day? If so, does this get boring or, if you will, monotonous? Is this a personally fulfilling career? Is it, dare I say, fun? Also, do DRADs tend to miss taking care of patients, or do people choose DR because of the comparatively small amount of patient care involved? Is there any substantial patient contact inherent in the job, or is that the realm of the IR docs?

    Any pros/cons of diagnostic radiology would be really appreciated.

    I can't get enough of this stuff…I've been literally staring at my MRI films and comparing them with Netter's Anatomy. What an amazing field of medicine!
     
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  3. Whisker Barrel Cortex

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    Although I can't answer all of your questions because I am just a 4th year med student applying to radiology residencies, I can give you my take on it.

    It seems you've discovered this amazing field a lot earlier than most. I myself didn't fully appreciate radiology until my third year in medical school when I did a preview rotation in our radiology department.

    What I like most about radiology is that it is in fact so varied. There are many different modalities, as you have experienced first hand (although an ECG is not read by radiologists). The intellectual aspect of radiology using these different kinds of imaging is phenomenal. Radiologists are required to know not only the normal anatomy of the whole body as it appears in diagnostic studies, they must know how disease processes in every field of medicine manifest. Most private practice radiologist skip from one kind of study (i.e. CT body) to another (mammogram) during any given day. Although IR radiologist do the most procedures and have the most patient contact, many general radiologists and body imaging trained subspecialists do abcess drainages, CT and ultrasound guided biopsies, and other procedures. I must admit that most radiologists do seem to read films for the majority of the day. If lots of patient contact is what you're looking for, this is not the field to choose.

    If you like technology, anatomy, variety, and quick procedures, radiology is the best field out there in my opinion. Although I'm sure reading chest X-rays or mammograms for a whole day could get boring, the fact is most radiologists don't do the same kind of study all day (some do, especially in academic centers).

    There are also many options for subspecialty such as neuro (cool stuff, also do neuro angiograms), body imaging, musculoskeletal, vascular / interventional, women's imaging (mammo, breast ultasound), and others. Most people with specialty training who go into private practice don't necessarily just do just their field, they are expected to read many other kinds of studies but are the experts that people come to in their field of expertiese.

    Just one caveat, if you do a radiology rotation in medical school or tail a radiologist, don't expect to be overly excited because there is little responsibility for students so it is hard to stay interested all the time. Picture yourself as an attending or resident to get more of an idea of what it will be like.

    Also, radiologists are some of the nicest and most laid back people in medicine, which means a lower stress lifestyle. Although money and hours worked should be lower on your list as reasons for choosing a specialty, you should know that radiologists are one of the highest paid specialties out there and generally work less hours. Both of these may change with time, so make your excitement for the field be your main deciding factor.

    Good luck.
     
  4. Voxel

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    I am biased. :) But, I find radiology to be a very fascinating field and fun! While other docs/ms may look at me funny, I love this field, even with the lack of patient contact. I do not believe the loss of patient contact will make me unhappy. Will it make you unhappy. I do not know. This is something you must decide for yourself. I find it tremendously exciting and intellectual. It provides me opportunities to use my head (know anatomy in 2D/3D, pathophysiology, pathology), but also my hands as well. Reading scans does not get boring but you must realize that at least 50-80% of the scans you read will not show pathology (ie Normal/Negative). Having said that, the pathology will be diverse from almost every field of medicine. You will see some strange and fascinating pathology, but just not all the time. You will see more pathology than the average office based primary care doctor on a daily basis. You are getting all of their combined pathology (that can be imaged).

    Do you love/like new technology? Are you a technogeek (I am, but never forget to be an advocate for referred patients!). Radiology is continuing to push the envelope for new diagnosis and treatment options. Read today's New England Journal Article about the use of MRI coronary angiography. You can kiss diagnostic coronary angiograms (performed by cardiologists) good-bye within 5 years in most applications. This is one example of the hugh advances being made in this field.

    If you cannot imagine living without patient contact, you should consider interventional radiology (IR) or some other field. As an IR doc you probably will be expected to read films as well (not all places, but a majority). Patient contact usual comes from 1) IR procedures including biopsies and drainages which body imagers do as well as the IR docs 2) consenting the patient (more done as a resident) for contrast injection.

    Do you love to learn and want to keep up with monthly improvements in broad field of radiology? You will have to continuously keep up with the advances in radiology. This will mean reading 3-4 hours a night for your entire residency as well as lots of self-learning post residency. Maybe less if you are a genius, but for the rest of us, that means steady reading! You cannot be spoon-fed or learn on the job all that is needed to pass the boards (one of the hardest out there) or be a great diagnostic radiologist.

    Are you comfortable with the fact that you will not have your own patients, nor admitting privledges (unless you do IR)? You are not commander of the ship. Your role in medicine is a that of consultant without their own patients. You need to be able to live with that and all the customer service skills it takes to be a great radiologist. You need people skills when dealing with other clinicians. Many are not up to date with all the latest/most appropriate studies for their particular patient. How will you handle this?

    Most lay people will not truly understand your role in medicine. So when most people ask you what field you are going into, they will give you a blank look when you tell them radiology. Little do they know the central role your input will play in their healthcare in case they ever get "really sick". It has a low prestige in the community outside of the medical profession. Some in medicine may view you as "not a real doctor." But the smart ones will call on you to help them figure things out or confirm their suspicions, even the ones who think we are not real doctors.

    Right now I see a threat to the practice of radiology as I know it because there are not enough new radiologists being trained. Can you handle a future with more work including weekends, less vacation time, 24/7 coverage of radiology services and busy call?

    This also means other specialists are looking to do some of the more lucrative studies themselves. You cannot self-refer patients. This is a good thing for cost containment and appropriate studies being done. However, as more specialists perform their own imaging procedures, what will be left for the radiologist? The chest xrays and barium enemas? There is a growing trend of non-radiologists performing the high-end MRI and CT procedures to bolster their income. Will you be prepared/want to wage this battle by doing what it takes to make referring physicians happy and not letting them muscle in on radiology's territory?

    There will be a battle (roy-al) with the cardiologists as cardiac MRI angiography replaces coronary angiograms and cardiologists source of $. Cardiac MRI angiography is cheaper ($1K vs 5K) than coronary angiograms and it is much LESS INVASIVE. These Cardiac MRI services will need to be 24/7 in the ED. Guess what? Call will be busier than usual. Assuming we can actually hold on to our technologic advances.

    Are you (not you specifically) a whiner, who does not want to work, but collect a high pay check. If so, please do us a favor, do not go into radiology. Find another field, please! You will be dissappointed as radiology turns into one of the hardest working fields in medicine. I know of radiologists that work from 7am-8pm M-F and 1 in 4 weekends and nights on call.

    Let me say one final thought. Leave your mind open to other fields. I discovered radiology as 1st year medical student and my advisor/mentor is a radiologist. He and I both agreed that I should keep "an open mind." As you finish your third year clerkships, you may find one of those fields fascinating. Also, if you have time get exposure to fields that you probably will not do third year. These include (depending on your school): opthomology, neurosurgery/neurology, orthopaedics, pathology, dermatology, radiation oncology, urology, anesthesiology, ENT, plastic surgery, Physical Medicine and Rehab (PMR), ER.

    (If you want to see all these fields in one way or another you probably will see them in radiology).
     
  5. Hedwig

    Hedwig Senior Member

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    Thank you both very much for your thoughtful and insightful responses. You've helped a lot. In light of the above, then, let me ask, With other non-rad docs doing their own imaging studies, does the diagnostic radiologist have a secure future in, say, 10 or 20 years?
     
  6. Voxel

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    There are no garuntees in life. You have to be flexible and adaptable. The good thing about radiology is that there are always technological advances. If the advances outpace the encroachment, we will be ok. If we provide high quality service and there is enough volume for everyone we will be ok. But 10-20 years from now is a long time. You and I will have to live that long. Your opportunities to practice in rural areas will probably be there because there will probably not be enough specialists trained to do their own exams.

    Right now according to medicare data, atleast 91% of MRIs are still performed by radiologists.
     
  7. droliver

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    Hedwig,

    Some examples of other specialists that will do some of their own imaging.

    -some FP/IM offices have their own x-ray machine for cxr's and extremity films

    -some Neurosurgeons & neurologists read their own films

    - orthopedic surgeons do a lot of their own imaging. This is a big political hot-potato @ some hospitals!

    -cardiologists interpret their own cath studies & ECHO cardiograms. Some cardiologists have gotten into peripheral vascular dz. imaging & endovascular tx. (a BIG disaster waiting to happen )


    -vascular surgeons are going to take over peripheral arteriograms (and possibly cerebrovascular a-grams) and endovascular tx. for peripheral artery dz. & AAA's

    -some critical care surgeons are placing Greenfield filters @ bedside under fluro


    Voxel's point about coronary MRA's is an interesting advance. IF it pans out it will be a huge advance, but it will be a long time before something as controversial as that would become widespread. A similar advance involves MRCP which could theoretically decrease the # of diagnostic ERCP's done (although these are much less impressive and useful than advertised IMHO)
     
  8. Voxel

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    Read today's NEJM and tell me what you think. I think it is not a question of IF coronary MRAs will pan out, but WHEN they will take over.

    I have to disagree on vascular surgeons taking over cerebrovascular imaging and therapeutics. I would not want to be the patient when that happens. I also disagree that vascular surgeons will take over peripheral angiograms. That is not a done deal. It depends on the environment. IR and vascular surgeons actually do work together and do it well.

    I still believe radiology is a great field, even with the "turf wars". :D
     
  9. droliver

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    Voxel,

    I think its a ? of when, not if radiologists get squeezed out for endovascular procedures. It's going to be increasingly cardiologists & the next generation of vascular surgeons (endovascular cases are now being required for fellowship training, which will soon be uniformly extended to two years to accomadate this)who do these cases. Ultimately the surgeon/cardiologist will get access to the patient first and direct the care & since they are now doing the angioplasty/stent and endovascular graft placements during training, I think they will gradually monopolize this field in most markets (especially if it is financially lucrative). Also,the vascular surgeons can always play hardball & refuse to provide backup coverage for botched endovascular cases by IR or cardiology.

    At present, I have only seen a little tension at some of the private hospitals we work at with IR trying to do some credentialing stonewalling with some of the surgeons for angiograms. As more & more practicing vascular surgeons pick this up & the # of new trainees increases(and the number of traditional bypasses shrinks quickly), this is going to quickly become dominated by surgeons.
     
  10. Voxel

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    I respectfully disagree. IRs are getting admitting priveledges and attracting their own patients without referrals. As for being backed up, I am sure there are plenty of general surgeons who will take the work, the variety, and the dough. Since when do surgeons refuse to cut. It's what they do. I think more IRs and vascular surgeons will work together in group practice. I'm not sure who will control what, but to think IR will be definitely shut out is being a bit premature. Especially when the number of exams to be performed are increasing steadily year over year. There may be enough work for both.

    I am not sure on your stance on neuro IR, but I highly doubt vascular surgeons will be doing this. The neurosurgeons will try to do it before vascular surgeons.
     
  11. droliver

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    Voxel,

    I too respectfully disagree :D

    1. There will be no line of surgeons waiting to take care of complications from someone else's endovascular procedures. This relationship only works with cardiothoracic surgery/cardiology because the CV surgeons depend on the cardiologist for their cases. Vascular surgeons do not depend on radiologists for cases, but radiologists do (in large part) depend upon referrals for arteriograms. Most vascular surgeons who do a-grams, increasingly are doing their own preop with an eye towards interventional measures. It makes no sense for them to have a radiologist do a diagnostic a-gram & then themselves have to come back & do another one for therapeutic purposes. This pattern will become increasingly prevalent in larger cities

    2. I don't think vascular or general surgeons will be rushing to do carotid stenting in the near (or distant) future. It's hard to improve upon a surgery with a small incision, low morbidity, and short hospitalization stay. The interest in this procedure (endovasc. carotid stenting) makes very little sense to people who treat this dz. regularly & CANNOT be recommended by anyone with a conscience.

    3. I don't think radiologists (or vascular surgeons) would want to join with each other in groups. There would not be enough a-grams & such to keep the IR compensated competatively as compared to what they make for all their imaging fees. Have you ever seen such an arrangement in private practice? It would be the first I've heard of

    I don't think routine arteriograms will be an area of contention. For that matter, I bet most future diagnostic studies will be MRA and not traditional a-grams (Wouldn't you agree, Voxel?). There will always be some x-over in these areas as you pointed out, but I can see the procedural/interventional vascular field leaning towards surgery vs. IR or cardiology
     
  12. Voxel

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    On point 1) I'm not so sure a general surgeon would not want the work as they will still get paid for this procedure I believe. I'm not sure how this would work politically if general and vascular surgeons are in a group practice or if there is a vascular surgeon on staff. That may be a problem. Not all lesions are ameniable to stenting, endovascular stent grafting, etc. If there is enough volume, there will be work for everyone.

    2) Neuro IR involves alot more than carotid stenting (which I believe is still experimental at this point). It involves brain aneurysms, glue, coils, TPA injections etc. That is what I mean by Neuro IR. I'm not sure how carotid stenting vs endarterectomies will play out. We shall see.

    3) There are some very famous institutions as well as private practices that have vascular surgeons and IR working in a group. They have more than enough work to keep themselves busy. In this case, the IR guy does not do any non-IR imaging.

    4) I agree that diagnostic angiograms will probably be a rare occurance when MRAs of most vessels can be better perfected. Why risk infection, rupture, anuerysms, hematomas, bleeding out?
    But the therapuetic end will still be hot. :)
     
  13. pags

    pags Senior Member

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    Dear God,

    Please let me match in radiology.

    Sincerely,

    Pags
     
  14. Hedwig

    Hedwig Senior Member

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    Pags,

    I'm curious. I too intend to go the osteopathic route. (Actually, let me rephrase that. Because my family has a very extensive history (and present) with osteopathic medical education, I'm not ALLOWED to become an MD!) I'd love to hear your experiences as a DO-to-be trying to match into radiology. Are you applying to osteopathic or allopathic programs? Do you know if the osteopathic programs are any good? Any information about your unique experiences would be greatly appreciated!
     
  15. Voxel

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    I know you asked Pags. Pags and I have had a discussion on this topic. Click on the thread below and read for yourself. As for having to go DO, think long and hard before you do that if you are serious about radiology. I do not know what the competition for spots will be 5 years from now. It is an important lesson to learn before you commit yourself to something you may regret later, especially if you had the option of going to a great MD school. You will get a great education at a DO school and be a great clinician, but being a DO puts you at a disadvantage compared to equally qualified MD applicants for allopathic radiology residency programs. Nothing is impossible, but making your life harder than is necessary is unwise. This is especially true since you may not be constrained for critical reasons such as ill parents or significant other but only because of "family pride".

    <a href="http://www.studentdoctor.net/cgi-bin/ubbcgi/ultimatebb.cgi?ubb=get_topic&f=11&t=000929" target="_blank">http://www.studentdoctor.net/cgi-bin/ubbcgi/ultimatebb.cgi?ubb=get_topic&f=11&t=000929</a>

    And who knows maybe you will like some other competitive specialty? Derm? Ortho? ENT?
     
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  17. pags

    pags Senior Member

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    Yes, unfortunately, this seems to be true and I am currently experiencing some of this discrimination. Read the thread provided for more detailed rhetoric. However, I'm finding that not having any radiology research under my belt is probably more of a problem (in getting interviews) than being from an osteopathic school. Speaking with more candidates along my interview trail, I am finding that my lack of research is a HUGE hole in my application, despite good grades, board scores, and great letters of recommendation (everybody seems to have these things). Thankfully, not all community programs harp on research which explains why the vast majority of my interviews are at this type of program.

    I did not have a strong DO influence beforehand and kinda "fell" into osteopathy after trying to get in any medical school for 3 years. So, my comments may be slightly biased, especially now. But Voxel is right, my education was of high quality and my fellow osteopathic colleagues and I will make excellent clinicians.
     
  18. Voxel

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    One other thought on the subject. If you want to go for an allopathic residency, it may be slightly easier to match into the residency program at your school. If you went MD and all else being equal, you would have a slightly better chance of getting into a radiology residency at your school. I'm not sure why this is true, but if you look at the matched list at some schools, more than half the spots are going to their "own" students. This would be another slight benefit to going MD. Also, if you went MD, you could get in research at that school, and if it's a school with great academic radiologist, your research and letters of recommendation will probably be more impressive. This is not impossible as a DO, but just makes life a little harder, especially trying to get your foot in the door at top academic medical centers.

    Happy New Year!
     
  19. ussdfiant

    Physician Moderator Emeritus

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  20. pags

    pags Senior Member

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    Good question. First of all, are you planning on an allopathic or osteopathic residency? Osteopathic are not as competitive. Plus, in 4 years, the radiology environment might be less competitive than it is now. I would start with talking to your school's radiology attendings about your ambitions. I believe UMDNJ has their own program in Newark. That's a great way to start. Ask about if there are any attendings that have active research interests. The type of research varies and I'm not a good person to ask about that anyway. Get involved with a radiology club at your school, if you have any, and if not, maybe start one. The idea here is to start early. I decided to go into radiology much too late and thought my grades/boards would elevate me above most. Not the case. Plan on doing exceedingly well in all aspects of medical school. High USMLE's are a must for DO's in the allopathic world. And, of course, obtain 1, maybe 2 great letters of recommendations from senior attendings, preferably at a residency program that you are interested in attending. It's really tough this year for DO's, but I've found that the DO's with the most and best interviews have done research in the field and have networked with residency programs in the beginning of their medical school career.
     
  21. Hedwig

    Hedwig Senior Member

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    PCOM has a radiology attending. He's pretty famous from what I understand b/c he teaches with puppets and songs. DO students from many schools come to PCOM and do rotations with him.

    (God, please make the next year and a half go by quickly so I can start PCOM soon!)

    Pags, what's the radiology residency at St. Barnabas like? I've heard it's quite good, and that the department is run by a very skilled MD radiologist. Is it extremely competitive to nab those 3 spots/year? Are there lots of applicants to these DO radiology residencies? Why didn't you consider it?

    Also, what is the scope of practice of a neuroradiologist? Is there such a thing as interventional neuroradiology, or is that essentially neurosurgery?
     
  22. pags

    pags Senior Member

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    I really don't know much about St. Barny's besides it's in the Bronx, headed by J.Peter Tilley, D.O., and the unhappiness of some residents through the grape vine. Osteopathic radiology has increased in competitiveness in the last few years, paralleling the allopathic world, but is inherently not as competitive. Realize this point, in general, osteopathic residencies are not appraised by most practicing MD's to the same quality of most allopathic programs and are located at smaller community based hospitals with less academia. Fair or unfair, it's a fact. I honestly thought my grades/board scores were of sufficient strength to land an allopathic residency. That remains to be seen. Also, the DO and MD match are offset to complicate the situation as well, which I will not go into on this post.

    Neuroradiology is a sub-specialty of radiology for an additional year fellowship. Interventional neuroradiology is a 2 year fellowship beyond the 4 year general radiology residency. There might be some overlap in procedures that neurosurgeons and IR neuro guys do, but I really can't answer that with any certainty.
     
  23. Voxel

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    Neuroradiologist without Neuro-IR training usually reads MRI/CT of head and neck and perform some diagnostic angiograms, but usually not therapuetics/treatment. That is where the neuro-interventional fellowship comes into play and they do lots of interesting and hair raising work, like injecting glue and coils into arteries in the brain to make them stop bleeding or bursting, injecting tpa directly into/onto a clotted artery in the brain.

    You should also know that in private practice outside of academia you will be expected to do general radiology outside of your "expertise" in neuroradiology.

    Neuroradiology fellowships can be 1-2 years in length and then you do a neuro-interventional radiology (Neuro-IR) fellowship 1-2 years. In most places it takes 3 years after 5 years of radiology (1 prelim/transitional year+ 4 diag radiology years). The way some people do both in 2 years is that they load up on neuro radiology during their last year of residency, but your residency program has to ok this arrangement. Thus, it usually means about 8 years of post-graduate training.

    Neurosurgeons (7 years of PGY training) can and do compete for spots in Neuro-IR fellowships and train in them. However, they are faced with a dilemma. They need a certain number of neurosurgical cases in different operations to remain board certified by american board of neurosurgeons. So, they can do neuro-IR full time and loose BC in NS or do NS full time and not practice neuro-IR but not both. This defeats the purpose of a N-IR fellowship unless one wants to dedicate themselves to N-IR. Honestly, a lot easier route (work hours wise) is to go through radiology residency than neurosurgery residency.
     
  24. Dr Sardonicus

    Dr Sardonicus Junior Member

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    Hey Pags,

    I am a first year at NYCOM. Rad is one of several areas I am interested in. Obviously, nothing is happening on campus in terms of radiology reseach. Do you know if there is any interesting work being done at our affiliated hospitals? Would it be appropriate to contact people out of the blue?
     
  25. Goofy

    Goofy Senior Member

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  26. Goofy

    Goofy Senior Member

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  27. pags

    pags Senior Member

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    Honestly, Dr. Sardonicus, I don't know of any right now. NUMC's program has some attendings that like to do poster presentations. I did my elective there and most of the attendings are very approachable. Plus, it is a main clinical campus of NYCOM. I know nothing about what's going on at St. Barny's. If I had to do it over again, I would pound on the doors of larger academic programs, such as SUNY Stony Brook, NSUH Manhassat, and some of the larger city programs and ask if you can shadow, wash their cars, shine shoes during your free time in the first two years. Then set up as many electives as possible at these programs that interest you very early in your 4th year.

    When it comes to specific questions about radiology, I forward you to Voxel. Obviously, I have no idea what I am talking about. Thank God on interview they don't ask me how much I know.
    :)
     
  28. Voxel

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    Come'on pags you are giving yourself too little credit. Seriously, you have given great advice on SDN.

    I will try to answer questions. I have tried to paint an unbaised picture of things even when people know I am going into this field. I try not to sugar coat things and am a realist, when friends ask for advice. However, professionally as radiologists, we must give our advice more gingerly and be PC. Sometimes, as a radiologist you just have to grin and bear it. Know what I mean? :D
     
  29. Voxel

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    Hey Kleb, what field are you going into/ or are in?
     
  30. laidback

    laidback Junior Member

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    Hi there, I'm a MS3 trying to decide between Diagnostic Rads and a pediatric specialty. I must admit I am becoming more concerned in face of the growing competitiveness of radiology. I did 1.5 mo of fMRI research at the NIH 2 summers ago but the lab never published the projects I worked on. I am at an institution with strong research and I was wondering what Voxel or Paqs' advice would be on doing more research. I don't know if I will be able to schedule more than 2 months of time before september, and I have only done 1 intro elective in diag rads...

    Any words of wisdom would be greatly appreciated!
     
  31. task

    task Senior Member

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    Per droliver:

    "-cardiologists interpret their own cath studies & ECHO cardiograms. Some cardiologists have gotten into peripheral vascular dz. imaging & endovascular tx. (a BIG disaster waiting to happen)"

    Oh please. Enough surgery bluster. With regards to cardiologists and peripheral intervention, I'm assuming you're referring (in part) to the endostent used in abd. aortic stenting -- the one that has had such dismal results and is being REMOVED in large numbers mainly because material from which it is made cannot withstand the high pressures of the abdominal aorta, and takes quite a beating. As a matter of fact, most Int. Cardiologists (and IRs) are staying away from abd. aortic stenting right now because of the high failure rate and the high rate of conversion to open procedures this stenting CURRENTLY entails. There is a new stent on the horizon developed by a Pediatric Cardiologist (whose name escapes me right now) that is the father of most of the interventional cardiac armory in use today that is much simpler to place and a 100x more durable in situ with the stated goal of its designer to make it available for Int Cards or IR guys to place. As for the rest of peripheral intervention, if you can balloon a moving target (the coronaries) and put a stent in it, the skills required of peripheral intervention are really no more difficult. Of course, if you don't know the anatomy, don't muck around, but most interventional cards fellowships incorporate peripheral training, or are beginning to do so in large numbers.

    With regards to carotid stenting, there are now proximally deployed umbrellas to catch microemboli before they get to the brain, that apparetly work. And whether surgeons like it or not, not everyone can tolerate anesthesia or the OR. Other options have to be available.

    As for complication rates -- take for example dissection. You should realize that now that Int. Cards is a formal 1-2 year training program past general cards (rather than ballooning a dog and a pig in Maui one weekend and then being qualified) the complication and failure rates are SO LOW now that the American College of Cardiology is planning to change credentialing requirements such that in the near future, coronary intervention does not have to be done with cardiothoracic backup. It is well known that in 97% of cases of coronary dissection, tamponading off the dissection with a balloon or even just watching and waiting is the primary and definitive treatment. The days of cath labs being vast killing fields where TCVS was being paged overhead to "fix all those botched interventions", to quote droliver, are long past.

    The above example illustrates a fundamental point. All procedures depend on proficiency. If you are proficient, generally speaking, your rate of complications will be low, even for a technically demanding procedure. Therefore, you should only do a procedure if you do it in enough numbers to be proficient at it. If vascular surgeons are going to get into the endovascular game, that means less time in the OR. I'm not sure if it pays for a surgeon to spend less time in the OR and more time in a cath lab.

    Another point. IRs are not clinicians. The idea that a radiologist would/could manage infectious complications, renal complications, or hemodynamic complications of one of their procedures is therefore kind of silly. It is this point alone that will keep IRs from achieving total autonomy that others are speaking about. They will always have to depend on others (primary care docs, surgeons, whatever) for patients. Hell, in residency radiologists barely follow-up a patient post-intervention. The politics of private practice necessitate them having to in real life. And now they want an admitting service?

    Medicine docs and medicine subspecialists control patient populations/referrals than any other field. If a case has to go to a surgeon, then obviously it must. But if it can be managed in a minimally invasive way by a medicine/medicine subspecialist colleague, then the referral pattern will tend toward that way first, logically.

    Finally, the much talked about coronary MRI article in the recent NEJM only discusses 3 vessel or left main disease. There are other vessels in the heart. Sure, resolution will become better with technology, but none of that changes the fact that if disease is found that is amenable to intervention, then a cath must be done anyway. This should be accounted for in any cost calculations (cost of cath + intervention vs. cost of MRI + cath + intervention). And don't count cardiologists out in the evolving role of coronary MRI. Mason Sones (the father of diagnostic cath) was a radiologist, and cardiologists effectively mastered (stole?) his technique and turned it into its current application in the heart. Don't doubt they won't be involved in the evolution (application and interpretation) of coronary MRI.
     
  32. Voxel

    Moderator Emeritus

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    If your read my original post you will see that I only said that diagnostic coronary angiograms will be replaced by MRI coronary angiography. I did not say who will be doing the MRI work. Yes, cards and rads will battle for the MRI work.

    Also no one denies that there will still be a need for coronary stenting. You must also calculate how much money is saved from preventing the complications of diagnostic coronary angiogram if no disease is found and how many coronary angiograms are replaced/prevented by coronary MRA. Also, when you do have a complication and do an coronary angiogram instead of MRI angiography and no disease is found, the malpractice lawyer will have his way with you. During your deposition: What do you mean DOCTOR, the MRI Machine was not available? What is that coin dropping noise I hear? Cha-Ching. Oh yeah, it's the lawyer holding you upside down by your ankles shaking you down for all your money.

    Task's comment:"Another point. IRs are not clinicians. The idea that a radiologist would/could manage infectious complications, renal complications, or hemodynamic complications of one of their procedures is therefore kind of silly. It is this point alone that will keep IRs from achieving total autonomy that others are speaking about."

    As for interventional radiologists not being able to manage renal or infections complications, I beg to differ. Your statements are not only inflammatory but insulting and not grounded in reality. Many of these IR docs did a year of medicine including ICU, ID, and renal experiences and manage their own patients on a daily basis. These IR docs could manage infections or renal problems or hemodynamic problems. If it becomes a big problem they would turf it to ID or Renal, ICU, just like cardiologists do today in similiar situations.

    Whether you like it or not, IR do have admitting privaledges and are getting them at many hospitals.

    And let me remind you doctor, that cardiologists depend on referrals from primary care docs, pulmonary docs, ER, ICU, and should I dare say surgeons, vascular or otherwise. The IR doctor is not alone in needing referrals for patients.

    Yes there will be a large turf war for interventional procedures. If domains are not respected, you will see cardiologists doing peripheral work, and IR and Vascular surgeons doing coronary work. No one will be happy to see that day.
     
  33. Voxel

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    traumeri,

    Research in fMRI at the NIH looks impressive on the resume, even if you did not get published. This is basic science research and not clinical research. Why not try to get involved with some clinical research as well. This way both the community radiology programs (who do not usually have bench research capabilities) and academic radiology programs will have something to discuss with you on interview day and you will be appealing to both types of programs.
     
  34. droliver

    Moderator Emeritus

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    Task,

    I will expound upon my comment for you and try not "blather". The experience we have here with IR/Cardiology doing peripheral angioplasty/stents has been a VERY frustrating. The technical aspect of doing endoluminal procedures is easily teachable as has been demonstrated by the #'s of radiologist, Cardiologist, and Surgeons doing them. What cannot be so easily translatable is picking which lesions and patients require or are appropriate for stenting in a clinical sense (vs bypass). This is a clinical skill that takes exposure and follow-up with peripheral vasculopaths to appreciate. An inappropriately done stent can transiently correct a problem, but can complicate peripheral surgeries & prematurely neccessitate amputation.
    In addition, as more vascular surgeons do this, THEY WILL NOT PROVIDE BACKUP for other specialties attempting it in some cases. Task, the future of peripheral vascular surgery is in endovascular work with traditional bypasses reserved for failure. I could see a future where the vascular surgeon spends more time doing angio than doing open cases & this ? of whether a surgeon would lose money by not being in the OR will be irrelavant- the angio-suite WILL be the OR. As you pointed out, endo-stents for AAA's are having their problems with endo-leaks & complications during the procedure. This highlights the fact that you cannot do a AAA repair without being prepared to open immediately. Again, cardiologist will not/cannot do them without backup & I just don't see anyone lining up to cover someone's ass on this especially when they don't think they should be doing them in the first place (I work with close to 15 vascular surgeons and they all say the same thing on this). As for carotid stenting, there are some very innovative strategies for doing this with endoluminal techniques being looked at, but again your advantage of doing this versus open is non-existant to most authorities in the field. I can't think of what population you refer to that you could do endovascularly that you couldn't do open- THE CONTRAINDICATIONS TO BOTH ARE THE SAME. (BTW you can do carotids under local anethesia) You can't plan on doing a stent if you are not prepared to immeadiately open - this is one of the principal tennets of endovascular work. Again, if you can't get someone to cover you for these, you(cardiology) won't do them for liability reasons
     
  35. task

    task Senior Member

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    "As for interventional radiologists not being able to manage renal or infections complications, I beg to differ. Your statements are not only inflammatory but insulting and not grounded in reality. Many of these IR docs did a year of medicine including ICU, ID, and renal experiences and manage their own patients on a daily basis. These IR docs could manage infections or renal problems or hemodynamic problems. If it becomes a big problem they would turf it to ID or Renal, ICU, just like cardiologists do today in similiar situations."

    Voxel -- there was no intention of being insulting or inflammatory on my part. 1-year of Internal Medicine or Surgery or a transitional year does not exactly make me, you, or anyone else an experienced clinician. No matter how much ID, renal, Unit time, or anything else you've done. I don't think IR docs don't have the time, inclination, or quite frankly the experience in the appropriate use of antimicrobial therapy. What about special considerations in giving contrast load to someone on metformin, or a patient who has CRI? How about an anaphylactic response to contrast? I don't exactly see radiologists running ACLS protocols on a daily basis. Sure, you can always call in consults and "turf" your problems, but the radiologists will have always have to depend on clinicians for these basic types of issues. That is not a slight against radiologists or IR specialists -- they are trained in other areas of expertise. As for cardiologists "turfing" to other fields -- you'd be surprised as to how much an IM board certified/board eligible, fellowship trained cardiologist can actually do outside of cards. Cardiologists send complicated or unstable cases to ICU, but it's a cardiologist taking care of the patient.


    "What cannot be so easily translatable is picking which lesions and patients require or are appropriate for stenting in a clinical sense (vs bypass). This is a clinical skill that takes exposure and follow-up with peripheral vasculopaths to appreciate. An inappropriately done stent can transiently correct a problem, but can complicate peripheral surgeries & prematurely neccessitate amputation."

    droliver -- no argument from me. As I stated in my original post, many interventional cardiology fellowships are expanding their curricula to provide such clinical depth, exposure and experience. Cardiologists are well aware of the fact that their percutaneous adventures in the coronary system have implications for patients who need to go under the knife later. Remember, most of the cardiologists picking up peripheral intervention now never went through any kind of formal training for managing these patients. They are translating their experience in coronary intervention to peripheral intervention. I certainly don't think this is right. But once the next generation of interventionalists comes out of training where they've had experience with these cases -- from diagnosis and evaluation to appropriate treatment (referral for surgery vs. doing a percutaneous procedure), then I think "the experience we have here with IR/Cardiology doing peripheral angioplasty/stents has been VERY frustrating" situation you describe might not be so much of a problem. Just an opinion.

    "As you pointed out, endo-stents for AAA's are having their problems with endo-leaks & complications during the procedure. This highlights the fact that you cannot do a AAA repair without being prepared to open immediately. Again, cardiologist will not/cannot do them without backup & I just don't see anyone lining up to cover someone's ass on this especially when they don't think they should be doing them in the first place (I work with close to 15 vascular surgeons and they all say the same thing on this)."

    droliver -- again, no argument from me. But as I touched on before, from what I understand, the technology for doint AAA stenting is evolving to a point where eventually ICards or IR docs may one day be able to do these types of cases. Much as the ACC is reviewing the thinking behind cardiothoracic backup in places doing coronary intervention, as experienced operators become experienced in peripheral intervention, these stipulations may come under scrutiny as well one day. Again, just an opinion.

    "If domains are not respected, you will see cardiologists doing peripheral work, and IR and Vascular surgeons doing coronary work."

    Voxel -- Coronary intervention is a whole other ballgame. This isn't just about sticking a catheter in some vessel. There is cardiac physiology & electrophysiology, the use of platelet inhibitors, the use of statins, glycemic control, and a whole slew of other things that distinguish coronary intervention from peripheral intervention. Much as I wouldn't want a cardiologist opening my chest to do a bypass, I wouldn't want anyone other than a cardiologist doing my PTCA.

    With regards to carotid stenting, contraindications to surgery include patients with symptomatic severe stenosis that is not surgically accessible, or patients who are at high surgical risk because of severe cardiac disease. These patients are candidates for stenting, at least under protocols of most of the major trials looking at stenting. However, a large, NIH-sponsored trial is just beginning. The Carotid Revascularization Endarterectomy versus Stent Trial (CREST) will include about 2500 patients from 40 US centers, randomized to either carotid endarterectomy or carotid stenting. Results of that trial though, are not expected for about 5 years. But for now, I do believe the standard of care is endarterectomy, done by surgeons with a very low complication rate, in properly selected patients.
     
  36. Hedwig

    Hedwig Senior Member

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    If I may, I'd like to divert the topic away from turf wars. Can anyone tell me, all things considered, what the job market for a non-subspecialty-trained general diagnostic radiologist will probably be like a decade from now? I realize that this is all conjecture and extrapolation, but I'm interested in what you think.

    Also, what are the malpractice premiums like for diagnostic and/or interventional radiologists? I imagine that they're astronomical, considering the implications of missing something on a scan. And hey, what's this I hear about DRs in New Jersey purposely misdiagnosing breast cancer (i.e., intentionally diagnosing it with no clinical basis) to avoid being sued for malpractice?

    P.S. I got a part-time volunteer internship in a busy NY radiology department and ER this summer. I can't wait. ...Never too early to start making those contacts and fulfilling that desire to learn more about radiology!
     
  37. Whisker Barrel Cortex

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    Although I think it is nearly impossible to predict the market in radiology 10 years down the line, I can give my take on it (as a 4th year med student planning on going into radiology).

    Right now the need for radiologists is high in most parts of the US. This has created the amazing market for graduating residents and fellows. I think there will be a couple of issues affecting this. First, there will continue to be a tremendous increase in the number of studies done as CTs are done faster and faster and the uses of MRI are increased. Since there is a limit to the number of new radiologists graduating and already a shortage, I believe this will lead to a great market for at least 5-7 years to come.

    However, as the technology and image quality improves and prices come down for this technology, more and more non radiologists will be reading their own films. I think this will quiet the market down eventually but not completely. If clinicians wanted to read studies for a living they wouldn't have gone into a clinical field.

    In terms of interventional radiology, I think the situation is up in the air. I do think surgeons and cardiologists will "steal" many IR procedures. However, the amount of these minimally invasive procedures will likely increase so that there will be work for everyone.

    The final issue, which will affect income but not job availability, is the almost certain decrease in reimbursement for studies by the federal government and insurance companies for radiologic studies. They did it to Pathologists and I am certain it will happen to radiologists too.

    All of that being said, 10 years down the line, the market will likely be weaker than now but not as bad as some would predict.
     
  38. neal

    neal Junior Member

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    hi,
    i am an img with average scores in USMLE. i am interested in DR but have heard that it is too difficult for imgs to get into it. if i do a preliminary surgery in a community hospital can it help me to get into DR? or if i do internal medicine categorical what are the chances of being able to switch? pls give ur opinions.
    thanks.
     
  39.  
  40. Voxel

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    Unfortunately you are applying at time when it will be difficult to match as an IMG. Here's the credentials of an IMG who matched last year. Step I, II 99, 98, have finished a complete residency in radiology in their country, came here did research with well known radiology faculty at a great hospital. Their match result was a small community programs that was high on workload and very low on teaching and research. Their also have been husband/wife/relatives to match at programs where their relatives had already matched.

    Also, doing any residency many be a plus or minus depending on how much money the department has in the bank. I'm not sure how medicare GME funding rules apply to IMGs. I hear that they get less for people who are not citizens or legal aliens, but I have not investigated this fully. This along with doing a residency will limit the amount of medicare funding the hospital receives for you. If you were to do some interesting specialty as it related to radiology such as orthopaedics it may help, but otherwise, I do not think it would make a difference. Maybe radiology will be less difficult/competitive some point in the future?
     
  41. Voxel

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    Task: "I don't think IR docs don't have the time, inclination, or quite frankly the experience in the appropriate use of antimicrobial therapy. What about special considerations in giving contrast load to someone on metformin, or a patient who has CRI? How about an anaphylactic response to contrast? I don't exactly see radiologists running ACLS protocols on a daily basis."

    Task, obviously you have not been in an IR suite day in and day out, if ever. And we radiologists are quite aware of metformin and contrast reaction as well as those that need to be premedicated for contrast reaction. We have even on occasion told medicine attendings/residents the regimen and have been disappointed because they did not premedicate. Every radiologist is trained to run ACLS protocols. We do not it on a daily basis, but an interventional radiologist runs ALCS code atleast 1-2 times per month (unfortunately). IR docs do see complications including infections and do write orders for medications including anti-biotics themselves. IRs even have their own admitting priveldges as well as dedicated beds for their patients to stay post-intervention. There are many radiologists who do IR atleast 90% of the time. They are not naive or unsophisticated as you make them out to be and are an almost completely different breed of animal than most diagnostic radiologists.
     
  42. task

    task Senior Member

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    Voxel,

    Where you train must be a completely different breed of program. If your interventionalists run ACLS protocols, then great. Where I train (one of the most eminent academic medical centers in the US -- meaning that I would assume it would be pretty representative of the norm, not the exception) Medicine wears the code pagers, and when a code is called in Special Procedures (the IR suites), we haul ass down there to invariably find two radiologists standing away from the patient, some nurse doing chest compressions, and no one really running the code. So actually, I have been in an interventional suite before. And when I float Swans in the CCU/ICU, I do those in the fluoro rooms we have in our units. So even as a Medicine resident, I do have some experience in percutaneous procedures, and even the use of fluoro.
    Furthermore, I never said or assumed anyone was unsophisticated. All I'm talking about is being trained to be a clinician. Radiologists/IR docs are not trained as clinicians. They are trained in a completely different skill set -- one that I don't know how to do, and one that I rely on Radiologists to do well every day. I freely admit that I cannot read a CT or MR with any level of proficiency besides seeing big bad things that are obvious. To that end, anyone can read a protocol and tell the primary team to stop Metformin or to premedicate or prehydrate a patient. How about starting the patient back on Metformin? What about managing their diabetes while off metformin? And while anyone can even write for antibiotics, there is (or should be) a lot more thought to doing this than I think you give credit for. And if you're going to tell me that an interventional radiologists knows as much about the appropriate use of antibiotics as an internist or a surgeon, you've got to be kidding me. Where I train, once IR does their procedure, then hands are off the patient. There is no daily rounding on the patient to check on the drain they put in or even check vitals, let alone examine the patient. All they do is their procedure. Which is fine, if that's all you want to do.
     
  43. badasshairday

    badasshairday Vascular and Interventional Radiology

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    10 years later, Vascular surgery has taken a huge share of the peripheral artery interventions, and Diagnostic Radiology job market has cooled off but not crashed. So I guess the predictions in this thread were not so far fetched. lol.
     

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