Is radiology going down?

[billybud]

Firstly, radiologists are diagnostic physicians of the utmost importance; how anybody can argue their utility and significance in modern medicine is beyond me.

Oddly enough, I am stuck between the two disparate fields---while I'm interested in the visceral rush of surgery I'm wondering if this will get old as the lifestyle/residency wears on me. In a more basic sense, there are times when I can't wrap my head around the idea of motor memory and manual labor for the rest of my life. Surgeons are very bright, no doubt about it, but are they utilizing their intellectual horsepower as they could in other fields? As you can tell, I'm on the radiology bandwagon for the moment... This is subject to change by tommorow.

for clarification--indecisve ms3 here

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[f_w]

Why not be enthusiastic?

Enthusiastic is good, rude and condescending is bad.

I am glad that my job as a radiologist affords me a good quality of life (e.g. right now hanging out on a bed with a laptop doing online CMEs while my kid is playing with some toys on the carpet rather than running through the hospital to work off the pile of overnight admissions like my friends in IM and surgery). I am also happy about the fact that my work is compensated quite well. I work hard for it during the week, but once I walk out the door, someone else is set up to take care of the odds and ends. But what would possess me to disrespect the FPs or general surgeons that send all of their business to me in the way the indian does, I don't know.

 

[threemae]

But what would possess me to disrespect the FPs or general surgeons that send all of their business to me in the way the indian does, I don't know.

Exactly. I would say that I have a healthy level of enthusiasm for radiology right now, but apache is over the top in coming into every single thread and declaring the absolute supremacy of radiology over every single field. For 80% of the psychiatrists that I know, I don't think any amount of money or short hours would make them enjoy radiology, and I'm glad they've found something that makes them happy. Similarly for surgery, I have been very impressed by their involvement and knowledge of critical care after surgery; in many cases they have struck me as equally capable as the IM docs in treating most patients.

Again, modern medicine is just way too big for anyone to do by themselves. Specialization is the fundamental cornerstone of the practice of modern medicine and the world economy as a whole. We should be proud of how our individual strengths and training apply to making us excellent docs at a given specialty instead of engaging in these constant pissing matches over the internet about who has the, "biggest," specialty that can do the work of other specialties as well.

Unless you're living some sort of crazy fantasy life where you go off into some South American jungle to practice surgery, rads, and FP for a tiny village, there's no effeciency or added competence that comes from knowing a little bit about everything.

 

[kamehame]

But what would possess me to disrespect the FPs or general surgeons that send all of their business to me in the way the indian does, I don't know.

Oh yeah, I don't mind being polite to them for business reasons, but in the backs of our minds we all know who's on top!

 

[f_w]

Oh yeah, I don't mind being polite to them for business reasons, but in the backs of our minds we all know who's on top!

I don't know who's 'on top'. They do what they like, I do what I like. I get more money and have more control over my schedule, but that doesn't put me above them by any means.

We have two general surgeons at our hospital. One works 9-5, does mostly colonoscopies and biopsies and doesn't operate on-call unless you really arm-wrestle him into it. The other one is a bit of a maniac who schedules elective cases for sunday am (before church) and saturday evening (after hockey practice). Both love what they do and wouldn't want to switch places with the other one. Is either one of them 'on top' of the other ?

 

[nima123]

I don't know who's 'on top'. They do what they like, I do what I like. I get more money and have more control over my schedule, but that doesn't put me above them by any means.

We have two general surgeons at our hospital. One works 9-5, does mostly colonoscopies and biopsies and doesn't operate on-call unless you really arm-wrestle him into it. The other one is a bit of a maniac who schedules elective cases for sunday am (before church) and saturday evening (after hockey practice). Both love what they do and wouldn't want to switch places with the other one. Is either one of them 'on top' of the other ?

Yeah, the one who doesn't go to church on Sunday is on top of the other!

 

[kamehame]

I get more money and have more control over my schedule

That's why we're the alpha males, dude!

 

[driedcaribou]

Med school and residency are NOT your life -- the OTHER 40 years after that are your life. If you're a strong applicant pick RADS or DERM. If you're only middle of the road pick GAS. If you're weak pick GAS in the boonies. DO NOT pick surgery. 10 years down the line you can drop me a line thanking me.

peace

I understand you like radiology a lot. It is true surgery is a tough life but I am left wondering about your opinion on something.

If radiology was the be all and end all, why doesn't everyone become radiologists? I realize that radiologists are the most experienced at dealing with imaging but still, many doctors in other specialties still interpret imaging themselves. I almost wonder if it is litigation that makes everything go through radiology.

And shouldn't we be trying to make all specialties a bit 'easier' just so you have 'happy' people filling all the necessary jobs in the medical system? One day someone you love will need a surgeon and I would hope that they find one that did their job with some care.

I don't see it being very constructive to antagonize your future and current colleagues considering you'll be sent patients from them.

 

[H_Caulfield]

Just to repeat what I've already said: this obnoxious person has certain criteria for which career is "best," and he's assuming we're all holding the same criteria. To him, a job is something that should be as easy as possible while offering the best pay and the most free time. If that were what I wanted out of my career I might be stoked about radiology as well.

Note, again, that the AFTER RESIDENCY you urge everyone to look at involves a lot of call and late hours even for radiologists. The guys at my hospital say if they only work 40 hours per week they'll make about as much as an internist; the average is about 60 per, and it's becoming well documented.

Finally, I'm not sure how you've concluded that my having House as my avatar necessarily means I want to be just like him, and that I'm thinking medicine must be just like it appears on FOX. I know damned well that the show is unrealistic, but I happen to think it's FUNNY.

I never suggested that you couldn't get into surgery, but only that you didn't go into it because you were a little scared of the lifestyle. The most common regret I hear spoken among residents here is that they chose a less exciting field in exchange for more free time. They're always wondering how it might have been if they'd really GONE FOR IT. I certainly wasn't questioning your ability to match into general surgery.

And again, I appreciate radiology. I considered it briefly. I understand its importance. When people start asking you what the difference is between you and a doctor, return and let us know how king-of-the-hillish you feel then.

 

[ndspider]

I think radiology is a great field of medicine.

Too bad I am applying to neurology.

In fact, as a future neurologist I plan on doing fellowship in neuroimaging.

Of course radiologists think I am crazy. Little do they know we are already stealing their interventional procedures.

I think as neurologists we undersand the functional anatomy better than radiologists, and that we read the scans better than some non-fellowhsip trained radiologists. I know I sure as hell won't send a radiologist up to the wards to work up a stroke victim or some type of cortical lesion.

Besides, you don't go to the ER to see a radiologist. So I just see doing a fellowship in neuroimaging a way to eliminate the "middle man." Fortunately so do the fellowship programs popping up here and there.

Similar to what cardiology did to you guys ehhh? As neurologists- we got nothing else to do eh? I mean we really don't "treat" anyone do we.

Your thoughts....

 

[OHMAN0125]

I think radiology is a great field of medicine.

Too bad I am applying to neurology.

In fact, as a future neurologist I plan on doing fellowship in neuroimaging.

Of course radiologists think I am crazy. Little do they know we are already stealing their interventional procedures.

I think as neurologists we undersand the functional anatomy better than radiologists, and that we read the scans better than some non-fellowhsip trained radiologists. I know I sure as hell won't send a radiologist up to the wards to work up a stroke victim or some type of cortical lesion.

Besides, you don't go to the ER to see a radiologist. So I just see doing a fellowship in neuroimaging a way to eliminate the "middle man." Fortunately so do the fellowship programs popping up here and there.

Similar to what cardiology did to you guys ehhh? As neurologists- we got nothing else to do eh? I mean we really don't "treat" anyone do we.

Your thoughts....

LOL. Neurology as a field is no where as lucrative or competitive as radiology. BTW. Interventional neuro is mostly done by neurosurgeons now in my area and not IR. It's been like this for years now. Good luck fighting with them.
Oh btw...if you didn't already know... because of imaging cuts it's very hard to be profitable in imaging from self-referral now. Only LARGE cardiology groups can still get a profit from imaging. However, for radiology groups the cuts meant that you only needed to increase imaging volume by an insignificant amount. You get it? ACR lobbied and won to make imaging less profitable for all these self-referring imaging clinicians.

 

[ndspider]

LOL- great reply silly boy

Maybe the people in minnesota are crazy then. (Link)


Good luck finding a neurosurg that wants to fellowship after residency to stick cath's in people and abandon surgery.

How will it be difficult to make a profit if I charge to not only examine the patient but read the scan?
Or what if I was part of a neurolgical group (10+ neurologist + neurosurg). I can't imagine they would have a problem having a neuroogist reading their scans- in fact that is now what the fellows going to the Dent institute are telling me.

LOL-

 

[nima123]

I don't know, man. This outsourcing thing is kind of scary. I just read an article on the Journal of the ACR about how radiologist are playing less important roles in the hospitals as outsourcing becomes more popular.
(Vol. 3, issue 8, Aug 2006, P 572-4)

Technology is a double-edge sword and I feel like it could back-stab rads at some point.

 

[OHMAN0125]

I don't know, man. This outsourcing thing is kind of scary. I just read an article on the Journal of the ACR about how radiologist are playing less important roles in the hospitals as outsourcing becomes more popular.
(Vol. 3, issue 8, Aug 2006, P 572-4)

Technology is a double-edge sword and I feel like it could back-stab rads at some point.

Outsourcing will be a minor issue unless the government says they don't require a US boarded radiologist to sign the final report. In my point of view, isee it this way, to outsource you have to take a US boarded radiologist and have him go overseas. This will inherently decrease the supply in the US. But most likely what these outsourcing "companies" do is hire ONE US radiologist to sign off on like 10 indian, chinese, etc. radiologists reads. I don't see the majority of radiologists taking this liability risk for a "castle" in india when they bank 500k here. It's all about that signature in the end.
Same thing with my wife's profession of pharmacy, yeah robots and techs can do everything, but in the end you need that signature cus the pharmacist is US boarded. And let me tell you the demand and salary for pharmacist has shot straight up because of the increase of meds and prescriptions. I see this analogy to be similar with radiology and the massive increase in imaging. I mean comeon the internet and high-def monitors aren't new, nighthawk has been utilized by many community hospitals for years, and yet radiologists demand only continues to increase with the use of pan-scanning. In fact, i'm wondering how much i can make if i agree to read overnight scans for a group in the future. I think it will save the hospital money since they wont be paying that australian group and the final read in the AM.

 

[OHMAN0125]

LOL- great reply silly boy

Maybe the people in minnesota are crazy then. (Link)


Good luck finding a neurosurg that wants to fellowship after residency to stick cath's in people and abandon surgery.

How will it be difficult to make a profit if I charge to not only examine the patient but read the scan?
Or what if I was part of a neurolgical group (10+ neurologist + neurosurg). I can't imagine they would have a problem having a neuroogist reading their scans- in fact that is now what the fellows going to the Dent institute are telling me.

LOL-

How am I silly? Neuro is one of the least competitive and attractive fields. You can't compare it with rads, derm, gas, or surg. I'm not arguing that neurologists do endo procedures if you read my post correctly. I said that neurosurg does most of the procedures and NOT IR. So go fight with them about it, and not rads. Oh btw, go ask any neuro group and see if they own a 64 slice CT or MRI. Oh wait, they dont got the money for them. And go ask your attending neurologist and see who finalizes the read.

 

[ndspider]

"Who finalizes the read" wait.... you think we actually read what you put on the "final report" HA!
Give me a break. My attending neurologist does, the pgy 4 does, the pgy 3 does, and sometimes the freaking pgy-2 catches things you miss!. Your department is part of "hospital policy" Fear for your jobs and outsourcing as imaging resolution increases and technology gets better.

64 slice CT? God your a dork.


The last thing I wanted to start is a flame war. Bottom line is I plan on reading my own scans. I highly doubt I will be taking any money from your pockets so don't worry about that. As far as the IR. It is a fact that neurology will be playing a bigger role in that field.

As for me, I plan on focusing on movement disorders.

 

[peduncle]

I think that we can all safely say that if MONEY and LIFESTYLE were on our minds.... medicine in general was not the right way to go.

 

[hans19]

Come on guys, I don't need this mess before RSNA. Play nice or I'll have to lock the thread.

All specialties have something to offer. I would disagree with some of the comments made about NIR, in the majority of places, Radiologists perform the procedures, but in many places Neurosurgery is gaining inroads. In the future, the field will be dominated by neurosurgery, just as vascular surgery does the bulk of peripheral interventions (as they can offer both surgery and endovascular interventions).

Neurosurgeons, theoretically, can clip AND coil. They can place EVDs or do a craniotomy if the patient infarcts and the brain swells. Interventional neurorads have the best catheter skills in general. Neurologists, one the other hand can't clip and they have the least experience with catheters, in general.

 

[OHMAN0125]

"Who finalizes the read" wait.... you think we actually read what you put on the "final report" HA!
Give me a break. My attending neurologist does, the pgy 4 does, the pgy 3 does, and sometimes the freaking pgy-2 catches things you miss!. Your department is part of "hospital policy" Fear for your jobs and outsourcing as imaging resolution increases and technology gets better.

64 slice CT? God your a dork.


The last thing I wanted to start is a flame war. Bottom line is I plan on reading my own scans. I highly doubt I will be taking any money from your pockets so don't worry about that. As far as the IR. It is a fact that neurology will be playing a bigger role in that field.

As for me, I plan on focusing on movement disorders.

Hahahahaha....see you in the newspaper from a suit one day.
Sorry Hans, but ndspiders comments invite flaming especially in the Rads site.

 

[supercut]

When I did my IR fellowship, we admitted all of the patients that needed admission to our own service (unless they had a primary service that wanted to keep them such as onc or VS)


/QUOTE]


REALLY??? WHERE??? I've never seen this. In my experince, IR does the procedure, and then writes 3 orders...Admit to Vascular, bed rest for X hours and resume home meds. Then it's up to the vascular service to round on the pt, figure out what the heck the home meds are (because it's not in the pre procedure paperwork), do the discharge paperwork, and deal with any complications.

Also I've had medcine call surgcial consult for malfunctioning IR placed G tubes...always after calling IR and being told to call surgery.

I had no idea that any IR people took care of their own pts. (seems like a great gig...do the procedure, bill for it, but never have to round/followup/take care of a complication!)

 

[peduncle]

I think gradually IR will actually have to take care of their own patients. I've seen this trend in my own hospital as the years go by. One of my residents had to ask me to refresh him on how to admit a patient.. haha

 

[OHMAN0125]

I think gradually IR will actually have to take care of their own patients. I've seen this trend in my own hospital as the years go by. One of my residents had to ask me to refresh him on how to admit a patient.. haha

Hmm....that would probably mean more "clinical" training is required beyond that 1 intern yr then. That would suck.

 

[dphoenix]

I think radiology is a great field of medicine.

Too bad I am applying to neurology.

In fact, as a future neurologist I plan on doing fellowship in neuroimaging.

I think to do a neuroradiology fellowship you have to have 4 years of DR residency. I dont think any programs yet take neurology residents; not to burst your bubble, but just to make sure you have the facts straight before you apply to Neuro. If you really want to do neuroimaging, you should go into radiology.


INR on the other hand will take neurologists after they have done a Stroke/ICU fellowship

 

[f_w]

I've never seen this. In my experince, IR does the procedure, and then writes 3 orders...Admit to Vascular, bed rest for X hours and resume home meds.

90%+ of IR patients don't need admission in the first place. They come in the morning go home in the afternoon.

Btw, what is considered a 'dump' on the planet academic medicine is considered a 'valued consult' in the community world.

Then it's up to the vascular service to round on the pt, figure out what the heck the home meds are (because it's not in the pre procedure paperwork), do the discharge paperwork, and deal with any complications.

That is the 'old' model of IR and few VS services these days would allow their IR colleagues to be used this way (hospitalist services on the other hand will be glad to take your inpatient admissions, that is what they get paid for.)

Also I've had medcine call surgcial consult for malfunctioning IR placed G tubes...always after calling IR and being told to call surgery.

I can't count the number of times I have replaced, unclogged, upsized, downsized various drains tubes, g-tubes, g-j-tubes at the request of surgery.

I have sent one g-tube to surgery, and that was after a neurosurg PA who wasn't familiar with IR placed g-tubes cut the T-fasteners after a day and allowed the tube and gastric wall to come loose.

I had no idea that any IR people took care of their own pts.

The complexity of 'taking care of patients' is overrated. On the medical and surgical services, the brunt of the decision making on simple inpatients is done by PGY-2 and 3s. After 2 years in clinical medicine, 4 years of rads and 1 year of IR writing some admit orders or laying hands on some aching belly is well within the purview of my field.

Also, running the inpatient end of things can easily be farmed out to a well trained PA or NP. Writing those pesky home-meds, and calling in some phone orders doesn't require rocket scientist training.

Most of primary IR admissions are pretty straightforward. Uterine artery embos, chemo-embo or various renal access procedures can be admitted in a very protocol driven manner. If a patient is a multi-modality wreck, they might benefit from admission to a different primary service. But in those cases, there is often a good reason for the primary service to admit the patient in the first place (e.g. a nephro patient who has lost his access, decompensates and hits the ER should go to nephro/hypertension service rather than IR or surgery).

 

[RADRULES]

I am a practicing RAD - I have a big salary and an even bigger schlong!

I am the king of all that matters in medicine.

 

[-Goose-]

Man there are some REALLY CLUELESS med students around here hehe -- I am really incredulous at their utter stupidity

House Dork: Regarding hours and salary, you have absolutely no idea what you're talking about so I suggest you go back to Kindergarten and start reciting your alphabets. "The guys at your hospital" -- exactly numnut. You are a geek and your friends are self-selected geeks and dweebs and it doesn't surprise me that they're not doing too well financially -- just like you won't. For every one goof you tell me about I can cite 3 mid 30's rads working 40 hours/week making 600+. Put that in your pipe and smoke it you pimple popper. The difference b/w me and a "real doctor?" -- are you kidding me? Being thought of as a "doctor" is a friggin insult these days boy -- I'd like to be as far away from that pile of poop as possible. You really need a reality check son... been watching far too much TV.

ndpsider: This is so friggin laughable that I won't even correct you. Great idea. Brilliant. Go into neurology to "steal" all of our oh-so-lucrative procedures hahaha -- that is classic -- I'm gonna tell my rads buddies about your post... they'll get a kick out of it. It's like saying that after I go you're gonna wipe for me hahaha. Knock yourself out neuro geek!

Your post is res ipsa. The simple fact that there are people like you in rads, if anything, would be a strike against the specialty.

1) This has nothing to do with me "liking radiology a lot." I actually don't love it, I just think it's the best among an otherwise very bad heap of choices. There's a lot of easier ways to make money in life than being a doctor, and I plan to pursue them.

Sounds like you shouldn't have gone into medicine. Why don't you get out?

 

[PeepshowJohnny]

Radiology is indeed going down.

It's going down this Sunday at Madison Square Garden when the Macho Man tears Radiology limb from limb inside a STEEL CAGE! Ooooh yeah!

 

[Bahamian Doc]

Best. Thread. Ever.

 

[kamehame]

Like I said I'd venture that 80% of docs 10+ years out of residency wish they did in fact do radiology.

Stop being shy, dude, we both know it's 100%! Radiology is for the few and the proud and anyone who isn't in it is just ashamed to admit that they weren't good enough. There is literally no physician in the world who doesn't want to be in radiology!

 

[swannliz]

I'm curious, ApacheIndian, where did you go to medical school?

 

[kamehame]

You're wrong. There are only two kinds of people in this world, people who are radiologists and people who wish they could be radiologists. The few and the proud, baby!

 

[osli]

I realize that radiologists are the most experienced at dealing with imaging but still, many doctors in other specialties still interpret imaging themselves. I almost wonder if it is litigation that makes everything go through radiology.

Other docs can read most imaging well enough, just like midwives can deliver most babies in your home well enough and nurses can handle most cases of an irritating cough well enough.

But what does the midwife do if the cord is wrapped? What does the nurse do if there's cancer in the lungs? And what if the other doc gets a film that isn't just another "routine CXR"? That's why we train specialists... it isn't to handle all the routine stuff, but to handle those emergencies or rare cases that really require expertise in knowledge and skill.

And that's what is really cool about radiology to me. In this field, that expertise is at the crossroads of technology, medicine, anatomy, and pathology.

 

[driedcaribou]

1) This has nothing to do with me "liking radiology a lot." I actually don't love it, I just think it's the best among an otherwise very bad heap of choices. There's a lot of easier ways to make money in life than being a doctor, and I plan to pursue them.
2) Like I said I'd venture that 80% of docs 10+ years out of residency wish they did in fact do radiology.
3) This statement clearly demonstrates your naive foolishness. Do you think I give two hoots who interprets images or who reads my reports or not? I couldn't care less friend. The point is, I get paid for it. Back to the baseball analogy -- you can call or a ball or a strike to your hearts content... it doesn't mean squat. It's what the ump calls it that matters and the ump gets paid big bucks to do so.

I'm not sure how my post demonstrates 'naive foolishness' when you've equated that I said you 'like radiology a lot' and you've interpreted it as you 'lov[ing]' it. You like radiology because it pays you well but you're too busy attacking everyone and arguing for the sake of insulting others.

You missed what I was saying between the lines: At the risk of insulting other colleagues, radiology's role is almost redundant considering everyone can read a scan. But due to the nature of specialization, litigation and the volume in our societies, radiologists are needed for their expertise and to streamline the reporting process in order to free up the time of other physicians to do other things. You're wrong that you're the umpire. If another doctor reviews a scan and finds a mistake in a report, as uncommon that may be, you're getting a phone call because the treating doctor is the one whose ass is on the line.

I don't ever recall a radiologist being in the operating room during intraoperative imaging and only there writing the report much after the fact

 

[hans19]

I'm curious, ApacheIndian, where did you go to medical school?

Interesting question. I have my suspicions and if I am correct, he formerly posted under a different name and he is not a grad of a US med school.

At any rate, most radiologists I know are decent people. I hope that based on his posts, people don't get the impression that radiologists are obnoxious chest thumping triumphalists that bag on other specialties.

I agree totally with FW, all specialties are vital to the practice of modern medicine and patient care. No one specialty can do everything without the help of another service from time to time.

As much as I love radiology, that doesn't mean that everyone else should do it too, especially if surgery, medicine, or psych is their true calling. As I've been saying all along, people should do what interests them, but don't do it strictly for the money.

 

[f_w]

Interesting question. I have my suspicions and if I am correct, he formerly posted under a different name and he is not a grad of a US med school.

The juvenile exuberance and the style of blubber is reminiscent of the famous 'drcuts' who was planning to do teleradiology on a laptop on board of his private jet (if I remember there was a 'while being serviced by beautiful women' in there, but my memory might mix his character with someone else).

I agree totally with FW, all specialties are vital to the practice of modern medicine and patient care.

LoL, except maybe a certain breed of cardiologists....

 

[hans19]

The juvenile exuberance and the style of blubber is reminiscent of the famous 'drcuts'...

Funny FW, thats what I was thinking-- Great minds think alike.

LoL, except maybe a certain breed of cardiologists....

I was tempted to say this but left it out of my post. But you said it for me!

 

[driedcaribou]

At any rate, most radiologists I know are decent people. I hope that based on his posts, people don't get the impression that radiologists are obnoxious chest thumping triumphalists that bag on other specialties.

All of the radiologists I have met except for one so far were really nice people who weren't arrogant at all (save the baseline arrogance all of us as doctors have ). It's always surprising to run into one who is such a chest thumper.

 

[Zweihander]

You missed what I was saying between the lines: At the risk of insulting other colleagues, radiology's role is almost redundant considering everyone can read a scan. But due to the nature of specialization, litigation and the volume in our societies, radiologists are needed for their expertise and to streamline the reporting process in order to free up the time of other physicians to do other things. You're wrong that you're the umpire. If another doctor reviews a scan and finds a mistake in a report, as uncommon that may be, you're getting a phone call because the treating doctor is the one whose ass is on the line.

From my own experience I would have to say that this comment is at best incomplete but certainly incorrect in certain regards. You're right that "everyone can read a scan." What you're wrong about is in assuming or implying that clinicians are able to read scans with the same level of sophistication as a radiologist: and that is the difference. Not being able to read a chest x-ray or glean some basic information from a CT scan is like not being able to read an EKG for MI: you need to do it all the time and you're in trouble if you're on at night and you can't. However, just as your average clinician doesn't hold a candle to cardiologists in diagnosing subtle arrythmias and the like, they also can't compare with radiologists in terms of commenting on things like lymphadenopathy, subtle masses, and many types of inflammatory changes.

You're also wrong about the "doctor's ass" being on the line with regards to images. Make no mistake: if a radiologist misses something on a read, it's HIS responsibility. This is in fact precisely why clinicians depend on radiologists -- because they don't want and can't manage the responsibility of having to interpret every film they read correctly. Even a cardiologist who is reading coronary CTs will have a radiologist on hand to interpret peripheral findings in the lung and soft tissues. If you are the final interpreter on any image, you are responsible for everything that can be seen on that image. It doesn't matter if you're doing a chest CT to rule out PE -- if you miss a soft tissue mass in the corner of the film that is found to be a malignancy, or fail to notice an aortic aneurysm that later dissects, that is indefensible in court.

None of this even approaches the role that radiologists play in actually designing the appropriate studies, deciding how much contrast to give and what phases of injection to take images at, and making calls regarding whether the inevitable imperfect film is adequate for the given indication or whether it is necessary to douse the patient with more radiation for a repeat study.

The bottom line is that clinicians need to be competent in reading films, but they are not (and aren't expected to be) experts at doing it. This is why the best results are obtained when clinicians consult directly with radiologists for complicated cases and share the clinical findings and historical background to aid the radiologist in more accurate interpretation.

I don't ever recall a radiologist being in the operating room during intraoperative imaging and only there writing the report much after the fact

This is institutional. I have seen on multiple occasions radiologists come to the operating room to assist in things like U/S-guided liver biopsies and the like. Some institutions will have techs who do this work, but I've also seen surgeons request specific radiologists to come and help them with some cases when they are uncomfortable with techs or feel the patient is particularly complicated, etc.

 

[-Goose-]

Totally agree. The thought of clinicians reading their own studies is laughable -- not a "threat" at all. Real "threats" are as follows:

1. NIR going the way of neurology and neurosurg
2. Vascular IR going the way of vascular surg
3. Renal IR going to urology
4. Coronary CTA going to cards
5. Non-vascular IR in general -- not tomorrow but perhaps in the not-so-distant-future -- being encroached on by gen surg
6. Increasing prevalence of telerad bringing DR salaries back down to earth
7. Offshoring of DR to foreign radiologists -- prelims in the forseable future. Finals not any time soon -- the political lobby is too strong to allow this to happen right now, but never say never. I'd give us at least another 10 years before this could happen.

Whoa there buddy!

One of the first sensible posts I've seen from you. Are you sick?

 

[AD2020]

Offshoring of DR to foreign radiologists -- prelims in the forseable future. Finals not any time soon -- the political lobby is too strong to allow this to happen right now, but never say never. I'd give us at least another 10 years before this could happen.
[/LIST]

For this to happen, it seems as though patients would have to accept offshoring of liability, as well. So it seems as though the political lobby is not the only force that is opposing offshoring. Or are you talking about a single US-certified radiologist signing off on reports done by many foreign radiologists?

Either way, when you say "this could happen", even if it's 10 years down the road, you're implying a change could happen rapidly (e.g. sudden drastic change in legislation 15 years from now). I've had the impression that offshoring would happen gradually, and that any gradual decrease would be more than compensated for by increases in technology and more widespread use of DR.

 

[rgarrig]

Real "threats" are as follows:

1. NIR going the way of neurology and neurosurg
2. Vascular IR going the way of vascular surg
3. Renal IR going to urology
4. Coronary CTA going to cards
5. Non-vascular IR in general -- not tomorrow but perhaps in the not-so-distant-future -- being encroached on by gen surg
6. Increasing prevalence of telerad bringing DR salaries back down to earth
7. Offshoring of DR to foreign radiologists -- prelims in the forseable future. Finals not any time soon -- the political lobby is too strong to allow this to happen right now, but never say never. I'd give us at least another 10 years before this could happen.

Thanks for the thoughtful post, Apache.

As an MSII interested in rads (among a few other specialties), this is the type of info that scares me off. I don't want to be a chicken little, but my father's career has been in jeopardy on many occasions due to #7 - off-shoring is a legitimate threat and I am not down with a 30+ year education and $100K debt only to discover that I need to re-specialize within a decade of starting my career. Makes hands-on (e.g. surgical) specialties sound all the better... any other thoughts on this?

 

[Zweihander]

Thanks for the thoughtful post, Apache.

As an MSII interested in rads (among a few other specialties), this is the type of info that scares me off. I don't want to be a chicken little, but my father's career has been in jeopardy on many occasions due to #7 - off-shoring is a legitimate threat and I am not down with a 30+ year education and $100K debt only to discover that I need to re-specialize within a decade of starting my career. Makes hands-on (e.g. surgical) specialties sound all the better... any other thoughts on this?

I'm curious as to in what manner offshoring has jeopardized your father's career.

 

[rgarrig]

I'm curious as to in what manner offshoring has jeopardized your father's career.

He's a computer engineer; over the last 10 years, he has survived wave after wave of cuts and outsourcing resulting in an 80% reduction in the US workforce of his international company. As a CS graduate, I saw a lot of my friends struggle to find jobs in part because of out-sourcing. There ARE opportunities in IT, but there would be a hell of a lot more if not for out-sourcing.

I have a phobia, so I'm making extra efforts to be rational about this. But I see not just outsourcing as a threat to rads, but computer software, too. It's possible to develop software that can (1) interpret images, ECGs, lab results, etc. better than seasoned doctors, (2) create internist machines that turn internists into mere lemmings who work with a computer program to 'input findings into a computer, wait for the computer to recommend follow-up tests, complete the tests, input the results into the computer, repeat until a diagnosis is made, follow Tx instructions", etc. As a computer scientist, I can see many areas of medicine where human minds can (and will) be replaced by computers. Now, some things really are just sci fi - e.g. it will be a very long time before a robot can actually perform a delicate surgery without any human oversight, but the examples cited above are really not that far off.

There are already computer programs that are better at analyzing and diagnosing particular diseases from particular imaging studies than practicing radiologists! True, these programs are over-specialized and even if they eventually gain widespread use, for a while radiologists will be needed to oversee the software and give some human validation to their findings.

Anyway, some of the above is pure speculation, some of it may never happen, and I cannot predict the future, so I will probably not worry about this too much.

I would love to hear any of your thoughts on these issues

 

[Zweihander]

He's a computer engineer; over the last 10 years, he has survived wave after wave of cuts and outsourcing resulting in an 80% reduction in the US workforce of his international company. As a CS graduate, I saw a lot of my friends struggle to find jobs in part because of out-sourcing. There ARE opportunities in IT, but there would be a hell of a lot more if not for out-sourcing.

I have a phobia, so I'm making extra efforts to be rational about this. But I see not just outsourcing as a threat to rads, but computer software, too. It's possible to develop software that can (1) interpret images, ECGs, lab results, etc. better than seasoned doctors, (2) create internist machines that turn internists into mere lemmings who work with a computer program to 'input findings into a computer, wait for the computer to recommend follow-up tests, complete the tests, input the results into the computer, repeat until a diagnosis is made, follow Tx instructions", etc. As a computer scientist, I can see many areas of medicine where human minds can (and will) be replaced by computers. Now, some things really are just sci fi - e.g. it will be a very long time before a robot can actually perform a delicate surgery without any human oversight, but the examples cited above are really not that far off.

There are already computer programs that are better at analyzing and diagnosing particular diseases from particular imaging studies than practicing radiologists! True, these programs are over-specialized and even if they eventually gain widespread use, for a while radiologists will be needed to oversee the software and give some human validation to their findings.

Anyway, some of the above is pure speculation, some of it may never happen, and I cannot predict the future, so I will probably not worry about this too much.

I would love to hear any of your thoughts on these issues

The issue of computer/IT jobs being outsourced is a very different one from radiology being outsourced, in my opinion. With software jobs, one of the issues is that it literally doesn't matter to the employer where the employee is located. In radiology, that is not quite the case. No institution at this point in time is willing to take on the responsibility of hiring *anybody* to do a radiologist's job. The jobs that are "outsourced" are still taken by American-trained radiologists who need to be board-certified to practice in the areas they are interpreting films, and many of them are workhorses that do preliminary reads only rather than final reads.

The danger for radiologists is in creating a situation where they do not offer anything to the clinician beyond the information available in a single reading. Currently, radiologists are truly medical consultants. Clinicians visit radiologists and seek their advice about pathology, disease course, and appropriate follow-up tests especially for their complicated patients. If radiologists STOP doing these things or rely to heavily on remote reads and this role dies away, then they will truly be in a position where it doesn't matter where they are. It's an active issue in the field and one which is very much the source of debate.

However, understand that even while all this is going on radiologists have more and more work to do and there is a significant shortage of them. Despite losing practically every turf war they get involved in and outsourcing, they STILL have more work to do today than they did yesterday. The reason for this is that medical care is married to imaging technology, and that technology is only getting more complicated, not less. We will always need specialists who know their way around these imaging modalities and are able to apply them to the science of medical diagnosis in a sophisticated manner.

As for computer programs doing radiological diagnosis -- which ones are you referring to? The only ones I know of are mammography programs and they have not been very successful -- certainly they have not lived up to the expectations people had for them.

 

[AD2020]

It's possible to develop software that can (1) interpret images, ECGs, lab results, etc. better than seasoned doctors, (2) create internist machines that turn internists into mere lemmings who work with a computer program to 'input findings into a computer, wait for the computer to recommend follow-up tests, complete the tests, input the results into the computer, repeat until a diagnosis is made, follow Tx instructions", etc.

Yes, it's possible to develop such software, but is it practical? Is it cost-effective? My guess to both those questions would be "no chance in our lifetime." I studied engineering as an undergrad - and all I can think of when you're talking about the possibility of computers replacing doctors are the practical obstacles at doing so effectively. I am intrigued by the software you mention - I've never heard of it but I would be willing to bet that it's capability is to look at a single type of rather narrow diagnosis in a single type of study, perhaps even in a single type of patient. You would have to do this for every possible diagnosis in every kind of study. In addition, you'd have to have a way for the program to take into account pertinent history provided by the clinician. Not to mention, each program would have to be painstakingly written to account for normal variation from patient-to-patient.... The list goes on. I wouldn't worry about it.

 

[threemae]

As for computer programs doing radiological diagnosis -- which ones are you referring to? The only ones I know of are mammography programs and they have not been very successful -- certainly they have not lived up to the expectations people had for them.

It's getting close in virtual colonoscopy.
http://www.thieme-connect.com/ejour...ssionid=F808B51464A26DFDA91E9A38D80081FA.jvm2

I've considered the issue a lot, and unfortuantely I don't have a lot of answers, but I suspect for a lot of screening tests that are looking for a singular type of well-defined pathology like mammograms or VC, computers might be able to outperform humans very soon. How this will translate into medico-legal issues surrounding practice, I don't know, but I certainly don't want to be counting on legal barriers to be protecting my career against patient interests or economic forces.

That said, these issues don't scare me off radiology. It will be a much, much longer time until a computer can be as effective as a human radiologist for reviewing scans that don't fit into neat little boxes. I have a little bit of background in neural-network simulation and even image processing via neural-networks, and they can do some amazing things, but they've got nothing on the flexibility and reasoning that a human can provide, and I suspect they never will.

If computers do manage to have that capability in my lifetime, it still doesn't scare me off of rads because every other field will be similarly affected, perhaps even earlier. Let's take endocrinology for example, a field that's pretty far away from rads. What if you could provide really precise complete mass-spec data about every single compound in someone's blood, fit that in with medical history and demographics, and you could probably have some sort of computer that would spit out the most likely pathology in endocrinology.

Basically, when computers and/or robots do finally rule the world, the economy will have altered so dramatically that it's really absolutely impossible to predict what field you should be in and maybe we'll all just lounge around on our vibrating couches watching holographic television in our Jetson's houses by then anyway.

Put another way, I think that diagnostic radiology is just about the most intellectually rigorous undertaking beyond pure science available to me as a career choice except for maybe law (which I don't want to do anyway), and therefore probably the last to get well and truly replaced by computers.

Similarly for teleradiology. It will definitely affect the market, but there's a severe shortage of appropriately trained radiologists period. Right now that works to the American patient's benefit (and American radiologists detriment) because of the income gap because they can afford to suck up radiologist intellectual resources from India, but in 20 years when the average Indian or Chineese person makes $25,000 a year, then it will be added market too. And we can do teleradiology for the Indian market while the Indian radiologists sleep and they can do our prelim-scans while we're fast asleep. Hell, even the Indian radiologists are pulling in $120 K, and that goes a lot, lot further in Bangalore than it does in New York.

My thoughts on it.

 

[MrBurns10]

Apache, you mentioned DR workload increasing in the near future (which I totally agree with) and that the result would be some offshoring to lighten the load. Any chance that instead of or in addition to this they'll just increase the number of residency spots and crank out more US radiologists? I'm currently an MSII so I doubt it would happen in the next couple years, if at all, but I was just curious.

 

[OHMAN0125]

They will... and they have been, but because of the lag-time b/w deciding to increase residency positions (and incumbent red tape) and having newly-minted BC'ed radiologist in the pool (5 years minimum), combined with DR demand growing at a much faster pace than predictions, this tactic has been failing for a number of years now. I remember I too was worried as a med stud that by the time I was done I may be too late for the party, but that is most certainly not the case from where I currently sit. How will the playing field look when you're done in 7 years? IR = guarded, uncertain, probably still good but not great. DR = very likely still at the top.

Honestly, in my opinion, offshoring will NOT pose a significant threat to rads salary or work in the future UNLESS the government decides that you don't need a US boarded radiologist to sign the final read. This is because I just don't think many US rads are willing to go offshores to make tons of money and sign off on foreign radiologist reads. I mean they can get into a lot of trouble with the lawyers when they find out you've been signing for 15 docs or something. And if the US rad goes offshore to read scans for like 6 months that effectively decreases the supply in the states the same. So I dont see it as a problem unless government steps in.

Thoughts?

 

[SquidDoc]

Boy I've opened a can of worms with this one. Here's the deal:

IR is the PREMIER procedure gig right now. But, there are a few issues/problems... I hate to say this, but the fact of the matter is, IR is just not that darn tough. You get a good gen surgeon in the IR suite for 6 months and he'll be ready to rock and roll. Ditto for NIR and neuro and neurosurg. This makes IR and NIR the low-hanging fruit for tons of disgruntled surgeons and neurologists who finally see the light. If IR supply filled current demand this wouldn't be an issue, but it doesn't -- demand far exceeds supply -- and that's a double-edged sword for current IR's -- it's what's drives their salaries sky-high, but it is what also leaves the market open for a correction... which is in this case other avenues to increase the supply... enter our surgeon and neuro colleagues. This only happening on a small scale today, but tomorrow is anybody's guess. And this is why I do not vociferously advocate IR to med students -- IMHO it's just not possible to say how the field will look in 5-10 years. IR's won't be sleeping under bridges, but they may being relegated to buying Benzes instead of Ferraris.

Diagnostic radiology is right now the PREMIER non-procedure gig in all of medicine and surgery. Period. Highest ROI by far. Higher than even IR. BUT the difference is that despite what many med students and clinicians and lay people thing, diagnostic radiology is NOT EASY. This is not me being pompous -- it is the truth... you only think it's easy because all you see are negative CXR's and the very obvious positive findings after the radiologist reports them. And your informal curbside interpretations before the rad gives his are fine and maybe right sometimes, but the difference is like walking across a 6 foot two-by-four on the ground vs. walking across a 6 foot two-by-four suspended between two skyscapers. Catch my drift? Anyway that alone prevents clinicians from being able to render their own formal reports and get paid for them.

The reason DR salaries are sky high right now is the same as that for IR's -- demand moving to the right and supply staying the same --> price point goes up. Microeconomics 101. It's not because we're so smart or divine or anything like that -- it's basic economics. Period. And imaging demand is ever increasing, in lock-step with medical litigation -- e.g. does the surgeon want to go straight to the OR with that clinicaly suspected appy... and take a small risk of a FP and consequent lawsuit... OR does he want to image? Of course he's gonna image... who can blame him in the litiginous society we live in? So DR salaries are inflated too -- it's a classic bubble. The market correction so far in DR is the emergence of telerad which is benefitting from centralization and commoditization and economies of scale... so that's bringing down salaries a bit, but not enough.

I predict that the next "big thing" in DR will be offshoring of prelim interpretations. A large public company very recently made public the results of a pilot study they conducted testing the waters with this, and they demonstrated very eye-opening results... good quality and dollars saved. But this sort of thing is MUCH MORE controversial than say -- neurosurgeons doing NIR -- so this won't happen enough to make a difference for a while... maybe 5 years, maybe 10, maybe more.

Bottom line: I still think DR (and IR if you really like patients and needles) are the way to go right now. My opinion may be different in five years, but right now although these gigs may take a hit in forthcoming years, they're so far ahead of the other fields right now that they can afford to do so and still be the best choices.

My little brother is an MS2 and this is the same advice I give him. Ok, off my soap box.

Excellent post. I am glad that I decided to match rads!

 

[driedcaribou]

stuff.

Those are good points and I hope you realize that I am by no means am trying to belittle radiology as a specialty.

But with some of your points, I thought we were agreeing on the same thing - esp. about the fact that clinicians do not want to take responsibility for interpreting scans which is why the radiologist does it. Though if you're a surgeon and you're going to make a cut, you're going to look at the scan yourself would you not?

I just think it is completely unfair to thrash other specialties and not give them support considering the level of teamwork necessary in health care.