Jumping Ship to Rads

[deleted941485]

midlevels in other fields is what’s led to the current radiology job market craziness.

Oh please they’re lemmings. All they’d need to do is put some hard stop on the computer ordering software or just give them an algorithm to follow that cuts down on imaging and voila al of a sudden the MLPs aren’t ordering as much

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[maxxor]

Oh please they’re lemmings. All they’d need to do is put some hard stop on the computer ordering software or just give them an algorithm to follow that cuts down on imaging and voila al of a sudden the MLPs aren’t ordering as much

People have been trying with AUC and other blocks, but volume's higher than ever. I don't think it's a good thing. It puts us under CMS magnifying glass...

 

[TheComebacKid]

Mid-level have not made inroads into imaging interpretation because it’s actually hard. It takes a lot of experience to get good at it which means reading a lot of volume for years and years. Chest X-rays are very challenging to read believe it or not., there is a lot of miss.

I fear this attitude is literally what will open up your entire specialty to be taken over by these vultures.

Yes radiology is hard. You know what else is hard? Emergency medicine. Interpretation of a high risk EKG, risk stratifying chest pain, putting in a crash cordis in a patient with a massive upper GI bleed about to lose their airway... It's not easy. It's also not easy being an anesthesiologist and dealing with a complicated airway in the OR or a patient who is crashing. It's hard to be a pediatrician and realize that the patient's fever is not "a cold" and actually Kawasaki's. All these specialties take "a lot of experience to get good at". Yet these specialties are overrun my mid-levels. That should clue you in: the people in the C-suite don't care about your experience. They care about how much you cost them (hint: it's a lot).

All of medicine is hard. Including radiology. But our work has shifted from having highly trained people provide the best care, to tolerating poor patient outcomes in the name of profits (i.e. CMG run sweatshops). I'm not exactly sure why you think rads is immune to this sort of takeover.

I would let go of the hubris, and the thought that "we are so smart and irreplaceable". I can promise you that same sentiment existed in this forum 10 years ago, and look how it turned out.

 

[thegenius]

I fear this attitude is literally what will open up your entire specialty to be taken over by these vultures.

Yes radiology is hard. You know what else is hard? Emergency medicine. Interpretation of a high risk EKG, risk stratifying chest pain, putting in a crash cordis in a patient with a massive upper GI bleed about to lose their airway... It's not easy. It's also not easy being an anesthesiologist and dealing with a complicated airway in the OR or a patient who is crashing. It's hard to be a pediatrician and realize that the patient's fever is not "a cold" and actually Kawasaki's. All these specialties take "a lot of experience to get good at". Yet these specialties are overrun my mid-levels. That should clue you in: the people in the C-suite don't care about your experience. They care about how much you cost them (hint: it's a lot).

All of medicine is hard. Including radiology. But our work has shifted from having highly trained people provide the best care, to tolerating poor patient outcomes in the name of profits (i.e. CMG run sweatshops). I'm not exactly sure why you think rads is immune to this sort of takeover.

I would let go of the hubris, and the thought that "we are so smart and irreplaceable". I can promise you that same sentiment existed in this forum 10 years ago, and look how it turned out.

I hear you ComebacKid. And I don't think this is a great comparsion. it's a good one, but not a great one.

Correct me if I'm wrong but 99% of the NP's and PAs are not resuscitating a dying UGIB patient or managing a crashing MI requiring defibrillation and intubation. The problem with EM is that the majority of what we see in the ER are not emergencies. The workup cannot be found in Tintinnalits or Rosens. It's people coming in for low-risk traumatic ankle pain, dental problems, hives, and a variety of other low-risk, stupid things that don't even need to come to the ER in the first place. And frankly, you don't need an ER doc to see these patients. If you go to the PMD's office with low-risk traumatic ankle pain, you'll be seen by a PA. So why does an ER doc have to see you in the ED? Why can't a PA see that patient instead?

I'm not a radiologist, but I don't know how this aspect translates to Radiology. What would a PA do, spend 6 months just learning how to read chest xrays? That's it? Nothing else? I bet you could train a non-radiologist for 6 months on how to read a CXR. After they look at 4,000 CXR's they are probably going to be pretty good. Just like a PA or NP who only does intubation or placing central lines. After you've placed 50 or so you are probably ready to do it yourself, unsupervised.

All of medicine is really hard...and unlike 50 years ago when there weren't so many tests we had to rely on pattern recognition and physical exam you needed a well trained doctor. Nowadays we rely on testing and binary instruments like rapid strep tests, Radiologists telling us if there is PNA on an CXR, and a variety of other "yes / no" answers to tests.

Maybe rads is subject to midlevel encroachment but I tend to believe the radiologists who have responded to this thread that it's a low-risk event in their field.

 

[Apollyon]

Rads and Gen Surg are two that come directly to mine about encroachment. No mid level is going to be primary on resolving a bowel obstruction, or a complex gall bag. Likewise, the films end up with an attending radiologist. A surgical PA isn't the surgeon, period, and the rads assistant is not the radiologist. It's like the cards NP isn't the one doing the cath. Period.

 

[Mount Asclepius]

Rads and Gen Surg are two that come directly to mine about encroachment. No mid level is going to be primary on resolving a bowel obstruction, or a complex gall bag. Likewise, the films end up with an attending radiologist. A surgical PA isn't the surgeon, period, and the rads assistant is not the radiologist. It's like the cards NP isn't the one doing the cath. Period.

And the midlevel doesn’t take care of the undifferentiated peri-arrest patient at the same time while also simultaneously managing an acute stroke, fracture-dislocation, miscarriage with hemorrhagic shock and pediatric stridor (p.s. these were also cherry picked out of the other 20 patients in the waiting room haystack with absolutely nothing wrong with them).

I agree with your point, I think.

Midlevels nibble away at all specialities of medicine, but they don’t get to the heart of each specialty. That won’t stop capitalism from trying.

 

[qwerty89]

Staffing a radiology department/section is also fundamentally different than an ER department/section.

With all the consolidation and mergers the norm in major metros are large radiology groups which allow for increased sub specialization. A neuroradiologist reading 100% neuro or body imager reading 100% body is not only for academics anymore. Subspecialization is also driven by the referring docs. At one desirable coastal CA private practice I interviewed at they told me I would not be reading any MSK MR since the local ortho docs specifically request only MSK fellowship trained rads to read them. Many pulmonologists only want chest or body imagers reading their HRCTs. Some ENT & Neurosurgeons only want neuro trained rads to read their cases, etc. As the referring docs get more and more specialized their demands for more specialized reads increases with it.

In academics each subsection functions nearly independently from one another. Breast handles all mammo, MR breast, tomo, and breast biopsies, needle locs, etc. Neuro handles all the neuro during the daytime and call is typically subspecialized. Same for body, MSK, IR, even peds, etc. Only exception is after hours at some institutions where there is an Acute Care/Emergency Radiology section.

My understanding is that outside of a few US or Tox trained ER docs, most ER docs are interchangeable.

 

[Mount Asclepius]

My understanding is that outside of a few US or Tox trained ER docs, most ER docs are interchangeable.

It’s both the beauty and downfall of this specialty that we have created. We are here 24/7/365 to handle whatever emergency you have. We do all emergencies. So yes, you have to be able to do that as it is implicit in the job description. 21st century health care realized though that we were interchangeable cogs. What we (the founders) did for the betterment of patient care was ravaged by business seeking the dollar.

 

[Taurus]

Lol. 🤣 I don’t dispute that every field is hard in its own way and that no field is better than the other. But you guys are missing the fundamental difference between radiology and a clinical field like ED. Radiology is more like pathology than EM. Meaning, images do not change and can be preserved forever. If I miss a cancer or rupturing AAA on a CT exam, my mistake can be preserved forever, unchanged and used against me in a lawsuit. In clinical fields, it’s mostly about what you document in the clinical notes plus labs and various tests. If you don’t document it, it didn’t happen unless you have other corroborating evidence. Please do a search of my past posts on this topic. I wrote extensively about it and I don’t want to rehash it again.

The big similarity between radiology and other desirable clinical fields like ortho is that we are one of the highest paying fields. Per hour, we do very well. I average like 40 hours per week 8-5 daily, weekend call every 6-8 weeks, and 15 weeks vacation. Who knows what the future is for any specialty is but I’m making as much hay as I can while the sun is out!

 

[Mount Asclepius]

In clinical fields, it’s mostly about what you document in the clinical notes plus labs and various tests. If you don’t document it, it didn’t happen unless you have other corroborating evidence.

It's mostly about missed diagnosis (occasionally mismanaged) plus an angry or upset patient/family. The beauty of Radiology is that you always have the shield of the ordering physician to also place the blame upon for missing a diagnosis on imaging, but more importantly as the one that has to have the interaction with the patient. The documentation matters, but it isn't the impetus for a suit. People have have bad outcomes irrelevant of your documentation and it's usually not your documentation that makes them angry. Testing also helps, but doesn't completely shield you either. Any image is just a snapshot in time. Understanding disease progression and when in time you capture that image is also important.

we are one of the highest paying fields. Per hour, we do very well.

We often tout in EM that we make the most per hour at the sacrifice of our poor schedule. That might not be true any more with declining reimbursement nationally. What does Radiology currently make per hour on average and at the upper/lower ends?

Who knows what the future is for any specialty is but I’m making as much hay as I can while the sun is out!

Agree completely.

 

[RuralEDDoc]

I’m late to this but I’ll add that I don’t think jumping ship is a good idea for many reasons. Minimum five years training since the fellowship requirement is real. Taking a step down on the medicine totem pole isn’t irrelevant as you go from attending back to trainee, many people struggle with that. On the relationship point, I disagree with prior posters saying that a strong marriage should easily survive such a move. Strong marriages can survive cancer and horrible life events, for sure, but one of the toughest relationship issues to work through is decline of income. Imagine taking that pay cut and matching in NYC or Boston or San Francisco or a half dozen other expensive cities. Man that would suck.

 

[RADRULES]

I admire and respect the ER docs I work with on a daily basis, it is a very tough job no doubt. They are part of a CMG I believe and they always seem a bit discontented.

I am not sure how mid-levels were able to make such large in-roads into the field and it is unfortunate. However, my opinion is that allowing the corporations to dominate the field was a much bigger mistake.... I assume there were many greedy ER docs who sold out at some point?

Mid-levels reading Rad studies is a remote threat. Based on the stuff I hear on the phone when they call me... "I see this thing on this image, do you see it??" I guess they could be taught but it would be a large investment of time and Rads themselves would have to teach them.

 

[maxxor]

I admire and respect the ER docs I work with on a daily basis, it is a very tough job no doubt. They are part of a CMG I believe and they always seem a bit discontented.

I am not sure how mid-levels were able to make such large in-roads into the field and it is unfortunate. However, my opinion is that allowing the corporations to dominate the field was a much bigger mistake.... I assume there were many greedy ER docs who sold out at some point?

Mid-levels reading Rad studies is a remote threat. Based on the stuff I hear on the phone when they call me... "I see this thing on this image, do you see it??" I guess they could be taught but it would be a large investment of time and Rads themselves would have to teach them.

Do not underestimate the greed of a baby boomer when the possibility hiring cheaper labor presents itself.

 

[Brigade4Radiant]

I’m late to this but I’ll add that I don’t think jumping ship is a good idea for many reasons. Minimum five years training since the fellowship requirement is real. Taking a step down on the medicine totem pole isn’t irrelevant as you go from attending back to trainee, many people struggle with that. On the relationship point, I disagree with prior posters saying that a strong marriage should easily survive such a move. Strong marriages can survive cancer and horrible life events, for sure, but one of the toughest relationship issues to work through is decline of income. Imagine taking that pay cut and matching in NYC or Boston or San Francisco or a half dozen other expensive cities. Man that would suck.

Especially considering that this is self imposed. Infidelity and money issues are the biggest reasons for divorce.

You may also have to move to a different city for fellowship. It’s not just a decline of income it’s the decline. It’s the decline the moving to a new location and working more hours then you would as an attending for half a decade.

Also if this spouse had to deal with medschool and residency this is a lot.
I mean you wrote a personal statement went on multiple interviews and completed a residency now you want to do it all over again but longer!??!

 

[TheComebacKid]

I hear you ComebacKid. And I don't think this is a great comparsion. it's a good one, but not a great one.

Correct me if I'm wrong but 99% of the NP's and PAs are not resuscitating a dying UGIB patient or managing a crashing MI requiring defibrillation and intubation. The problem with EM is that the majority of what we see in the ER are not emergencies. The workup cannot be found in Tintinnalits or Rosens. It's people coming in for low-risk traumatic ankle pain, dental problems, hives, and a variety of other low-risk, stupid things that don't even need to come to the ER in the first place. And frankly, you don't need an ER doc to see these patients. If you go to the PMD's office with low-risk traumatic ankle pain, you'll be seen by a PA. So why does an ER doc have to see you in the ED? Why can't a PA see that patient instead?

I'm not a radiologist, but I don't know how this aspect translates to Radiology. What would a PA do, spend 6 months just learning how to read chest xrays? That's it? Nothing else? I bet you could train a non-radiologist for 6 months on how to read a CXR. After they look at 4,000 CXR's they are probably going to be pretty good. Just like a PA or NP who only does intubation or placing central lines. After you've placed 50 or so you are probably ready to do it yourself, unsupervised.

All of medicine is really hard...and unlike 50 years ago when there weren't so many tests we had to rely on pattern recognition and physical exam you needed a well trained doctor. Nowadays we rely on testing and binary instruments like rapid strep tests, Radiologists telling us if there is PNA on an CXR, and a variety of other "yes / no" answers to tests.

Maybe rads is subject to midlevel encroachment but I tend to believe the radiologists who have responded to this thread that it's a low-risk event in their field.

You bring up fair points. But just like our specialty has lots of mundane/dumb things that we pawn off to midlevels, not every single imaging study is very complex. Also, why can't you train midlevels to exchange g tubes and nephrostomy tubes and do fluro-guided LPs?

In terms of reads, I'm sure a midlevel will miss some stuff. But if you have one attending supervising them who takes the responsibility, I don't see how its any different than what we do in the ED.

Maybe you are right, perhaps radiology is more protected. But I think becoming passive and acting like you are untouchable is a recipe for disaster. 10 years ago, nobody in our specialty thought that the easy work i.e. dental pain, ankle pain etc would be pawned off to midlevels. We thought we were untouchable. And we didn't protect ourselves appropriately.

 

[Taurus]

It's mostly about missed diagnosis (occasionally mismanaged) plus an angry or upset patient/family. The beauty of Radiology is that you always have the shield of the ordering physician to also place the blame upon for missing a diagnosis on imaging, but more importantly as the one that has to have the interaction with the patient. The documentation matters, but it isn't the impetus for a suit. People have have bad outcomes irrelevant of your documentation and it's usually not your documentation that makes them angry. Testing also helps, but doesn't completely shield you either. Any image is just a snapshot in time. Understanding disease progression and when in time you capture that image is also important.

Lol. 😅 One of my side gigs is expert witness in radiology malpractice lawsuits. In these lawsuits, it truly is black and white. You either missed it or you didn’t. You either found the most pertinent findings, made the right recommendations, and called the critical findings, or you didn’t. The lawyers give me the images and ask me what I see. Even without the lawyers telling me what happened, I can usually decipher quickly what happened and how you messed up. After that, the lawyers figure if there is any wiggle room for their client or if they should settle. Everything revolves around the images in radiology and images don’t change and can be preserved forever.

 

[Taurus]

In terms of reads, I'm sure a midlevel will miss some stuff. But if you have one attending supervising them who takes the responsibility, I don't see how its any different than what we do in the ED.

Lol. 😄 I’m assuming you are talking about diagnostic imaging studies? This is the difference between radiology and clinical fields like ED, primary care, or anesthesia. Midlevels in diagnostic radiology do not improve our productivity. After the midlevel reviews the imaging, the radiologist has to sit down and review the studies too. Now, it’s double the work and the time. Any ethical radiologist will not blindly sign off on a midlevel’s or resident’s report without reviewing the images too. If they do, it’s medical fraud and people have gone to jail for that. Remember, if the midlevel or resident screws up, the images are there for lawyers to access later. A radiologist will be most productive if they read their own studies. Anyways, I’ve posted about this a lot before. Do a search. I’m not going to rehash it. The comments reveal the level of misunderstanding that non-radiologists have about radiology.

 

[TheComebacKid]

Lol. 😄 I’m assuming you are talking about diagnostic imaging studies? This is the difference between radiology and clinical fields like ED, primary care, or anesthesia. Midlevels in diagnostic radiology do not improve our productivity. After the midlevel reviews the imaging, the radiologist has to sit down and review the studies too. Now, it’s double the work and the time. Any ethical radiologist will not blindly sign off on a midlevel’s or resident’s report without reviewing the images too. If they do, it’s medical fraud and people have gone to jail for that. Remember, if the midlevel or resident screws up, the images are there for lawyers to access later. A radiologist will be most productive if they read their own studies. Anyways, I’ve posted about this a lot before. Do a search. I’m not going to rehash it. The comments reveal the level of misunderstanding that non-radiologists have about radiology.

Sorry, and I'm not trying to be antagonistic, but I don't understand your rationale at all.

"Any ethical radiologist will not blindly sign off on a midlevels reports without reviewing the images". That's like saying "Any ethical EM physician will not blindly sign off on a midlevels chart without seeing and examining the patient themselves." The truth is, the latter happens everyday, where often times we are forced/mandated by the CMG we work for to sign off on their charts. I don't fully understand how radiology is different. Just because the images live forever? I mean, EKGs live forever? Lab values live forever? All parts of the medical record live forever...

In radiology, I think its conceivable to have an attending "supervise" a midlevel, whereby you are required to review 10-20% of their imaging studies and provide feedback. The rest, you just sign off on.

You guys have a lot of studies to read through, and they pile up, and affect disposition/decisions for patients. Hospitals, CMGs, patients etc want you to read them faster to improve throughput, for a lower cost. They don't care about whats ethical. Nothing about midlevel implementation is tied to ethics or what is best for patients.

I honestly hope that my comments regarding midlevel encroachment in radiology are wrong. But I think instead of pretending to be this untouchable specialty, it would behoove you to work towards way to ensure your space and your future is protected.

 

[skougess]

Agree with what has been said above. Stop thinking like a physician and start thinking like an MBA. Ethics, outcomes, patients….they don’t give a **** about any of it. All they care about is pushing the boundary of cheapness to its maximum limit.

You can’t fathom how midlevels could replace you because you can’t stop thinking like physicians. I can’t fathom how they replaced EM docs either, but here we are.

 

[Taurus]

In radiology, I think its conceivable to have an attending "supervise" a midlevel, whereby you are required to review 10-20% of their imaging studies and provide feedback. The rest, you just sign off on.

Lol. 🤣 Um, no. It’s called fraud. See below. Keep repeating this mantra: “Images do not change and can be preserved forever.” Let it sink in. Sleep on it. Once you accept it as fact, you will see how this is a beautiful, insurmountable moat that separates radiologist from midlevel. Radiology is like pathology where the images/slides do not change and be kept indefinitely. Both fields require a large fund of medical knowledge and practical training that requires medical school and residency. But unlike pathology, radiology is innovative and keeps pushing the boundaries into more lucrative tests like MRI and hence why radiology is one of the best paid specialties per hour basis.

Atlanta Radiologist Sentenced to Prison

However, the evidence showed that from May 2007 through January 2008, REDDY signed and submitted thousands of reports in his name without even reviewing the films that were the subjects of the reports. Rather, he had non-physician technicians known as Radiology Practice Assistants (“RPA’s”) review the film and prepare the reports. In some cases, REDDY directed the RSI staff to simply sign for him, and transmit the report as it he had prepared it. In other cases, REDDY accessed the system for the purpose of signing and submitting the reports. Either way, the majority of the time he never looked at and analyzed the underlying films, and the reports signed by him therefore did not bear his medical conclusions or those of any other doctor.

 

[emergentmd]

Im going to pull this up when Radiologist start to whine about the job market and cut rates. I don't know how its going to happen but it will.

Either with single payer setting lower rates. Either by lowering standard of care and allowing PA/NPs to read plain fills. Either by having PA/NPs do the plain film reads and having a 4:1 CRNA model.

Any specialty, esp hospital based, do not realize that Hospitals only care about profit and will do anything they can to cut down costs. If they see a radiologist costing them 5-700K, you bet that is a low hanging fruit.

I don't see what is to stop HCA from opening a bunch of residencies, bringing all of the radiology in house, and what are the private groups going to do?

If I were CEO of a hospital system, I would open a residency program tomorrow and flood the market with radiologist who will eventually beg to work for 300K/yr.

I am only a lowly ER doc and I can confidently say that I have missed less plain film reads that affected care vs how much more the radiologist read missed some obvious stuff that affected care. I don't even wait for an official read before making a disposition. Really what radiologist good for if they are not participating in my decision making?

 

[bravotwozero]

Im going to pull this up when Radiologist start to whine about the job market and cut rates. I don't know how its going to happen but it will.

Either with single payer setting lower rates. Either by lowering standard of care and allowing PA/NPs to read plain fills. Either by having PA/NPs do the plain film reads and having a 4:1 CRNA model.

Any specialty, esp hospital based, do not realize that Hospitals only care about profit and will do anything they can to cut down costs. If they see a radiologist costing them 5-700K, you bet that is a low hanging fruit.

I don't see what is to stop HCA from opening a bunch of residencies, bringing all of the radiology in house, and what are the private groups going to do?

If I were CEO of a hospital system, I would open a residency program tomorrow and flood the market with radiologist who will eventually beg to work for 300K/yr.

Agreed. That said, the more likely threat in rads is more residencies opening and creating an oversupply of doctors, not midlevels.

MLPs didn’t start working yesterday. They’ve been around for eons, long before most of us became attendings. If they were going to replace radiologists, it would have happened already

 

[maxxor]

On the one hand, my worst fear is some system (the VA for example) trialing NP image interpretation and then ispreading.

I know @Taurus thinks it won’t happen because of physician fear of liability, but I think someone somewhere will find NPs who are all about independent practice who will sign the cases alone.

On the other hand, we are often the first (and only), physician to “see” the patient in an ocean of mid-level care. I have interpreted exams that were ordered by the mid level PCP generating a referral to the ER where they were seen by mid level ER, and admitted to mid level hospitalist all through one call shift. No physician had signed any notes on the patient, except for my reports. In a way, we enable the midlevels.

 

[Kuratz]

Radiology is great, and IR is awesome (tho you do go back to some of the headaches of clinical medicine). Very happy as a PGY-3 in our call-heavy year. Actually enjoy going to work most days. That being said I wouldn’t choose to switch into this and retrain for 5 years if I were stuck in something else. The opportunity cost in medicine is enormous as it is. Another 5 years and effectively a 7 digit financial sacrifice on top of that is just not possibly worth it for the vast majority of people displeased with their current practice.

 

[Mount Asclepius]

Per hour, we do very well.

hence why radiology is one of the best paid specialties per hour basis.

We often tout in EM that we make the most per hour at the sacrifice of our poor schedule. That might not be true any more with declining reimbursement nationally. What does Radiology currently make per hour on average and at the upper/lower ends?

??

This is relevant to the financial implications of making a switch between specialities. Although, I don’t think you should switch from a well paying specialty to another well paying specialty based solely upon the compensation as it can change at a moment’s notice.

Lol. 😅 One of my side gigs is expert witness in radiology malpractice lawsuits. In these lawsuits, it truly is black and white. You either missed it or you didn’t. You either found the most pertinent findings, made the right recommendations, and called the critical findings, or you didn’t. The lawyers give me the images and ask me what I see. Even without the lawyers telling me what happened, I can usually decipher quickly what happened and how you messed up. After that, the lawyers figure if there is any wiggle room for their client or if they should settle. Everything revolves around the images in radiology and images don’t change and can be preserved forever.

I was speaking to how malpractice works in EM and clinical medicine. It is different compared to Radiology.

 

[Taurus]

On the one hand, my worst fear is some system (the VA for example) trialing NP image interpretation and then ispreading.

I know @Taurus thinks it won’t happen because of physician fear of liability, but I think someone somewhere will find NPs who are all about independent practice who will sign the cases alone.

On the other hand, we are often the first (and only), physician to “see” the patient in an ocean of mid-level care. I have interpreted exams that were ordered by the mid level PCP generating a referral to the ER where they were seen by mid level ER, and admitted to mid level hospitalist all through one call shift. No physician had signed any notes on the patient, except for my reports. In a way, we enable the midlevels.

I actually don’t care if they allow NP’s to read diagnostic imaging studies independently. What I don’t want is to have my name attached to their reports. If NP’s want independent practice in clinical fields as well as diagnostic fields like radiology and pathology, I say let them as long as they don’t hide behind some physician when they screw up. And you just know they will screw up big time again and again because they either lack the knowledge or the formal training. The beauty of radiology is that images don’t change and can be kept forever.

If NP’s read imaging studies independently, then my side gig as an expert witness in radiology malpractice lawsuits may become a full-time job. 🤣

 

[Brigade4Radiant]

Lol NPs are not held to the same standard as doctors. Especially with lawsuits. Most malpractice lawsuits the plaintiff loses anyway.

Physicians care about malpractice

Also you guys think CMGs care about lawsuits when they are rarely named. There is malpractice insurance.

Large corporations face lawsuits daily the do not care and it will not affect their bottom line

 

[clibby]

I actually don’t care if they allow NP’s to read diagnostic imaging studies independently. What I don’t want is to have my name attached to their reports. If NP’s want independent practice in clinical fields as well as diagnostic fields like radiology and pathology, I say let them as long as they don’t hide behind some physician when they screw up. And you just know they will screw up big time again and again because they either lack the knowledge or the formal training. The beauty of radiology is that images don’t change and can be kept forever.

If NP’s read imaging studies independently, then my side gig as an expert witness in radiology malpractice lawsuits may become a full-time job. 🤣

You can't testify against an NP. They practice nursing while you practice medicine. It is ridiculous and makes no sense, but their lobbying has protected them well. If you don't think corporate interests will beat out responsible, ethical medical practice, I have a bridge in Alaska to sell you...

 

[Taurus]

You can't testify against an NP. They practice nursing while you practice medicine. It is ridiculous and makes no sense, but their lobbying has protected them well. If you don't think corporate interests will beat out responsible, ethical medical practice, I have a bridge in Alaska to sell you...

Lol. Anybody who gets into the imaging game will be held to the standard of the community, which is radiology. If the patient has stage 4 cancer because of an independent NP reading the case missed it, that NP will be held to the standard of a radiologist. Believe it or not, I am expert witness in more cases where the defendant is a non-rad physician.

 

[skougess]

This thread would just be really sad if it wasn’t borderline offensive. “Radiology is special and untouchable, unlike those other specialties (EM, FM, Crit Care, Anesthesia, Peds, GI, Cards, Nephro, etc…) where the *easy* cases can be managed by a mid level”

I promise you guys aren’t safe. Stop thinking like ethical physicians. If they are okay with staffing ICUs with NPs with no supervision at night, you can bet they have no problem with having you rubber stamp images that a groups of noctors read under your medical license. It won’t be the noctor who missed the stage 4 cancer. It’ll be you who signed off on it. And YES you WILL once you realize that signing off on mid level studies are de facto requirements of being employed in the field.

 

[maxxor]

This thread would just be really sad if it wasn’t borderline offensive. “Radiology is special and untouchable, unlike those other specialties (EM, FM, Crit Care, Anesthesia, Peds, GI, Cards, Nephro, etc…) where the *easy* cases can be managed by a mid level”

I promise you guys aren’t safe. Stop thinking like ethical physicians. If they are okay with staffing ICUs with NPs with no supervision at night, you can bet they have no problem with having you rubber stamp images that a groups of noctors read under your medical license. It won’t be the noctor who missed the stage 4 cancer. It’ll be you who signed off on it. And YES you WILL once you realize that signing off on mid level studies are de facto requirements of being employed in the field.

I agree with you as a practicing Rad. I see the efforts to create a radiology midlevel as the latest push to open the floodgates to midlevel Dunning Kruger/ good enough medicine.

No offense to @Taurus , but I really think he’s in a unicorn group and can’t see the reality of modern corporate psychopathy. I’ve lived through an attempted corporate sale. It makes me identify more with what you ER guys have collectively experienced than any other specialty. I also completely disagree malpractice standard of care will remain radiologist level. Once MARCA (or similar legislation passes), attorneys will make the argument that RRAs should be held to their standard, much like NPs have.

 

[WilcoWorld]

Keep repeating this mantra

Mantras can not be argued with - they are accepted on faith, so there's no sense arguing with Taurus on this issue folks.

 

[Birdstrike]

I think this is a good mindset to have on this subject: "Like all skilled workers, I'm potentially replaceable. Therefore I'll think about ways to ensure myself against replacement (or partially replacement) by cheaper alternatives." It seems appropriate for the way Medicine appears headed in the 2020's.

In my opinion, that's a superior mindset to: "Because I'm irreplaceable so special, the world will always protect me against cheaper alternatives," which seems more suited to the 1970's.

 

[turkeyjerky]

With regard to midlevel takeover, I think rads faces a similar problem that we do. Namely, that the vast majority of studies are normal, akin to the vast majority of ED patients not having emergencies. This affords a great deal of protection to lesser trained practitioners. I really don't know much about it, but I don't see why techs couldn't do a 1-2 year training pathway and get 'certified' for initial reads of certain studies (this already happens with vascular US in my system, we practice based on the tech report).

I don't actually think Rads is in any imminent danger from this, though. They're probably at higher risk from other things, such as AI increasing efficiency by 20-40% or healthcare reform leading to a lower number of studies ordered. Or some other black swan event (who would've predicted that a once in a century pandemic would decimate the job market for EM?).

That said, for the OP, or anyone in similar circumstances, it's probably a good long-term decision to switch fields. 5 years of retraining is a long time, but you might be able to get another 15-20 years of practice in Rads after that. How much longer do you really think EM will be viable? I highly doubt anyone working for a CMG will be at >180/hr in 5 years.

 

[Birdstrike]

Physicians generally earn somewhere between $200,000 and $600,000 per year. Do you know which kind of businessmen don't want to replace highly paid workers with cheaper alternatives?

Only the stupid kind.

Forget PAs, NPs and AI. They're working on way to replace us that you haven't even imagined yet.

 

[Dave1980]

With regard to midlevel takeover, I think rads faces a similar problem that we do. Namely, that the vast majority of studies are normal, akin to the vast majority of ED patients not having emergencies. This affords a great deal of protection to lesser trained practitioners. I really don't know much about it, but I don't see why techs couldn't do a 1-2 year training pathway and get 'certified' for initial reads of certain studies (this already happens with vascular US in my system, we practice based on the tech report).

I don't actually think Rads is in any imminent danger from this, though. They're probably at higher risk from other things, such as AI increasing efficiency by 20-40% or healthcare reform leading to a lower number of studies ordered. Or some other black swan event (who would've predicted that a once in a century pandemic would decimate the job market for EM?).

That said, for the OP, or anyone in similar circumstances, it's probably a good long-term decision to switch fields. 5 years of retraining is a long time, but you might be able to get another 15-20 years of practice in Rads after that. How much longer do you really think EM will be viable? I highly doubt anyone working for a CMG will be at >180/hr in 5 years.

the problem with rads is that you cant fake it till you make it then way midlevels can in primary care and ER and you can't consult someone if you have a tough case.

You have to make the call and move on.

i also can't get away with recommending unless studies because it would slow down the whole er

 

[Franzd'Epinay]

Radiology is like pathology where the images/slides do not change and be kept indefinitely. Both fields require a large fund of medical knowledge and practical training that requires medical school and residency. But unlike pathology, radiology is innovative and keeps pushing the boundaries into more lucrative tests like MRI and hence why radiology is one of the best paid specialties per hour basis.

I hope for medicine's (and patient's) sake that you are right and diagnostic radiology proves to be completely immune to midlevel creep, but you are living in denial if you don't see the playbook that could be used against you:

1. Corporate groups make 2-year "fellowships" to teach midlevels "who want to practice at the top of their license" how to read films.
   1. They will justify this by talking about the Radiologist Shortage™ and to meet the needs of Underserved Areas™
   2. Boomer radiologists will participate in this sellout either out of greed or idiocy--maybe they will get some nice academic publications out of it too
2. Overconfident midlevels eager to "prove themselves" will flock to these programs, especially after seeing radiology salaries
3. Naive radiologists will talk about how great it is that the midlevels can read simple ankle sprain x-rays so they can focus on the very complex studies
4. Some radiologists will see how "competent" their group's midlevels are and will allow them to take on more complex studies to improve efficiency and reimbursement
5. Corporate groups will then require radiologists to "collaborate" with the midlevels on their staff
6. The midlevels will start lobbying for independence

Does that sound insane? It is; but that's exactly what has happened in every field where midlevels have gained a foothold. If you think your field is too complex for it to happen, then you are severely underestimating the hubris of midlevels and the greed of corporate medicine.

I'm just some dude behind a keyboard, but I guarantee you some private equity psychopath has drawn up a way more detailed playbook and is champing at the bit to implement it. Ethics and patient safety have nothing to do with it.

 

[Taurus]

I think this is a good mindset to have on this subject: "Like all skilled workers, I'm potentially replaceable. Therefore I'll think about ways to ensure myself against replacement (or partially replacement) by cheaper alternatives." It seems appropriate for the way Medicine appears headed in the 2020's.

In my opinion, that's a superior mindset to: "Because I'm irreplaceable so special, the world will always protect me against cheaper alternatives," which seems more suited to the 1970's.

I've been talking about midlevel encroachment for more than 15 years. I'm as aware of it as anyone. When I was picking my residency, I carefully thought about how that field would be impacted by midlevel encroachment. However, we should not make blanket assumptions that midlevel encroachment will affect all of medicine equally. It does not. There are pockets of medicine where there is such a great moat that is insurmountable for midlevels, either because of lack of knowledge and training, legal liability, or both. Surgery, pathology, and radiology are the fields that come to mind that are best protected from midlevel encroachment. In the case of pathology and radiology, the moat is created by the required fund of knowledge, practical training, legal liability, images/slides do not change and can be preserved forever, and probably most importantly in radiology the lack of productivity gain by using midlevels. Midlevels, like training residents, only slow down radiologists and do not increase our productivities. No ethical radiologists, who wants to avoid jail or losing their licenses, will blindly sign off on reports without reviewing the images too. Why? Because "images do not change and last forever." Keep repeating that to yourself. Any miss or screw up can be traced back to the original images and the report. As much as you guys desperately want to place radiology in the same sinking boat as ED, it is not. Misery loves company, right? There are significant structural differences between the two fields. The people who recognize this will benefit the most as they navigate their careers.

 

[skougess]

I've been talking about midlevel encroachment for more than 15 years. I'm as aware of it as anyone. When I was picking my residency, I carefully thought about how that field would be impacted by midlevel encroachment. However, we should not make blanket assumptions that midlevel encroachment will affect all of medicine equally. It does not. There are pockets of medicine where there is such a great moat that is insurmountable for midlevels, either because of lack of knowledge and training, legal liability, or both. Surgery, pathology, and radiology are the fields that come to mind that are best protected from midlevel encroachment. In the case of pathology and radiology, the moat is created by the required fund of knowledge, practical training, legal liability, images/slides do not change and can be preserved forever, and probably most importantly in radiology the lack of productivity gain by using midlevels. Midlevels, like training residents, only slow down radiologists and do not increase our productivities. No ethical radiologists, who wants to avoid jail or losing their licenses, will blindly sign off on reports without reviewing the images too. Why? Because "images do not change and last forever." Keep repeating that to yourself. Any miss or screw up can be traced back to the original images and the report. As much as you guys desperately want to place radiology in the same sinking boat as ED, it is not. Misery loves company, right? There are significant structural differences between the two fields. The people who recognize this will benefit the most as they navigate their careers.

You realize there are already a vast amount of pathology midlevels reading slides, right?

Administrators. Don’t. Care. About. Quality.

 

[Taurus]

No offense to @Taurus , but I really think he’s in a unicorn group and can’t see the reality of modern corporate psychopathy. I’ve lived through an attempted corporate sale. It makes me identify more with what you ER guys have collectively experienced than any other specialty. I also completely disagree malpractice standard of care will remain radiologist level. Once MARCA (or similar legislation passes), attorneys will make the argument that RRAs should be held to their standard, much like NPs have.

Lol. I'm just a partner in a 100+ radiology group in a highly desirable large city with 6+ years of private practice experience. I'm also on the faculty at the local medical school. I previously worked in a midsized group in a small to mid-sized city. I think I have a pretty good idea of private practice.

You want to know what is very rare? A midlevel who reads diagnostic imaging studies. My academic department at my residency actually had one who was treated like a perpetual resident and only did one modality, always needing to have the studies reviewed with an attending radiologist. However, we have none in our group. I don't know of any in any private practice. Why isn't it more common in private practice? Because midelvels, like residents, only slow down radiologists and decrease our productivities. Academia doesn't care much about productivity. You'll be lucky to see an academic radiologist pick up the dictaphone. However, they care very, very much about productivity in private practice. That's the #1 criterion whether to make someone partner.

It takes me 5 seconds to read a normal chest x-ray and 5 minutes to read a normal CT abdomen and pelvis. How is inserting a midlevel going to increase my productivity when I then have to review the images and their reports too?

This lack of productivity gain by using midlevels in diagnostic radiology is a huge reason why you rarely encounter a midlevel reading diagnostic imaging studies.

As someone else pointed out, if midlevels could be effectively used in diagnostic radiology, wouldn't they have figured it out by now? The fact that midlevels in diagnostic radiology are unicorns or at best zebras should tell you that it doesn't work.

But if any of you guys are geniuses and can figure out a way to overcome these obstacles I pointed out, tell the private equity firms and try to get a cut for yourself and retire early and rich.

 

[SeekerOfTheTree]

Man, this discussion took a strange turn. Thanks for all the advice.

I guess I like working but I want a job where I can keep working till I get old like 60. I don’t really care to retire early because I have enough hobbies but something about working is nice. Problem with ER is as I get older the shift switches seem harder. My gig and pay is good but if I did it past 50 I would kill myself. ER life just isn’t sustainable long term. I envy the old timers who do it into their 60s. What are they made of?

Would it make sense to put in 5-10 more years and then do a residency or not worth it at that point. This way money won’t be an issue as much as today. Part of me does get very burned out with what I do too so I guess it would be nice to sit in a room all day left alone reading picture. It’s not like in ER there is a fellowship that’s even remotely interesting.

I just want to comment on pathology; isn’t that field basically taken over by PhDs now instead of MDs hence the job shortages or am I misinformed?

 

[Birdstrike]

I've been talking about midlevel encroachment for more than 15 years. I'm as aware of it as anyone. When I was picking my residency, I carefully thought about how that field would be impacted by midlevel encroachment. However, we should not make blanket assumptions that midlevel encroachment will affect all of medicine equally. It does not. There are pockets of medicine where there is such a great moat that is insurmountable for midlevels, either because of lack of knowledge and training, legal liability, or both. Surgery, pathology, and radiology are the fields that come to mind that are best protected from midlevel encroachment. In the case of pathology and radiology, the moat is created by the required fund of knowledge, practical training, legal liability, images/slides do not change and can be preserved forever, and probably most importantly in radiology the lack of productivity gain by using midlevels. Midlevels, like training residents, only slow down radiologists and do not increase our productivities. No ethical radiologists, who wants to avoid jail or losing their licenses, will blindly sign off on reports without reviewing the images too. Why? Because "images do not change and last forever." Keep repeating that to yourself. Any miss or screw up can be traced back to the original images and the report. As much as you guys desperately want to place radiology in the same sinking boat as ED, it is not. Misery loves company, right? There are significant structural differences between the two fields. The people who recognize this will benefit the most as they navigate their careers.

I don't work in EM and my point is not that radiology will be replaced by mid-levels. You're missing my point entirely.

My point is that there are people who's entire jobs are to sit around and contemplate the 3 R's.

-Replace
-Reduce
-Require

Physicians cost to much. Find out ways to "Replace" them. Find out ways to "Reduce" what we pay them or their reimbursement. "Require" more of them. The people whose have these jobs are very powerful people. They are CEOs and politicians. They are much more powerful in the world of healthcare than any physician or group of physicians. Right now they're at a round table meeting in their non-physician suits and this is what they're saying, "I read on the internet today that some guy, thinks he's irreplaceable, his salary is guaranteed and his workload capped. He thinks he's immune."

"Lol. Let's get back to the three R's."

 

[thegenius]

I don't work in EM and my point is not that radiology will be replaced by mid-levels. You're missing my point entirely.

My point is that there are people who's entire jobs are to sit around and contemplate the 3 R's.

-Replace
-Reduce
-Require

Physicians cost to much. Find out ways to "Replace" them. Find out ways to "Reduce" what we pay them or their reimbursement. "Require" more of them. The people whose have these jobs are very powerful people. They are CEOs and politicians. They are much more powerful in the world of healthcare than any physician or group of physicians. Right now they're at a round table meeting in their non-physician suits and this is what they're saying, "I read on the internet today that some guy, thinks he's irreplaceable, his salary is guaranteed and his workload capped. He thinks he's immune."

"Lol. Let's get back to the three R's."

Jeez man you are one big party pooper

 

[Birdstrike]

Jeez man you are one big party pooper

Lol

 

[emergentmd]

I've been talking about midlevel encroachment for more than 15 years. I'm as aware of it as anyone. When I was picking my residency, I carefully thought about how that field would be impacted by midlevel encroachment. However, we should not make blanket assumptions that midlevel encroachment will affect all of medicine equally. It does not. There are pockets of medicine where there is such a great moat that is insurmountable for midlevels, either because of lack of knowledge and training, legal liability, or both. Surgery, pathology, and radiology are the fields that come to mind that are best protected from midlevel encroachment. In the case of pathology and radiology, the moat is created by the required fund of knowledge, practical training, legal liability, images/slides do not change and can be preserved forever, and probably most importantly in radiology the lack of productivity gain by using midlevels. Midlevels, like training residents, only slow down radiologists and do not increase our productivities. No ethical radiologists, who wants to avoid jail or losing their licenses, will blindly sign off on reports without reviewing the images too. Why? Because "images do not change and last forever." Keep repeating that to yourself. Any miss or screw up can be traced back to the original images and the report. As much as you guys desperately want to place radiology in the same sinking boat as ED, it is not. Misery loves company, right? There are significant structural differences between the two fields. The people who recognize this will benefit the most as they navigate their careers.

Ignorance is bliss. Its OK to think this and helps you sleep better. If I were a radiologist, I would rather think this and sleep well believing nothing will change versus a radiology resident who believes they are replaceable wondering what it is going to be like in 5-10 yrs when they start to practice.

Anyone who thinks reading plain film xrays is difficult is WRONG. Anyone who thinks an NP can't be train to read a plain film xray as good or better than a new radiologist attending is WRONG. I am only an ER doc and I can tell you that after 1 yr of ER attending practice, I could read a plain film as well or better than most new attendings and in line with most radiology attendings. Sure, I may not be able to give you 5 differential on a lesion, but I know it is a lesion and need follow up imaging.

Plain film xray readings can easily put to AI or a midlevel, I have no doubt about it.

But we are not talking only about midlevels. There are a slew of issues that will affect all specialists jobs including Rads.

Do you really think surgeons are protected? In the past when a small surgery group had too much work to handle, they would hire another surgeon. Now, they just hire a bunch of APCs to rounds on pts, do D/c instructions, see clinic pts, do call backs, etc. So yeah, an APC can't operate but they can do the other 80% of what a surgeon does and HATE. So yeah, essentially they ARE replacing surgeons. This goes with almost all specialties. Look on the floor and you will see APCs in almost all fields where in the past a doc was hired.

I invest/own FSERs so I actually own my building, own my patients, own my billing, and have a population that will never go back to the hospital ERs. During the pandemic we were seeing 60-90 pts/dy. We get pts sent to us from other doc offices b/c they know we do a better job. But still, I am well aware that I could lose it all tomorrow if carriers stop paying or some gov regulation outlaws FSERs.

 

[Taurus]

Ignorance is bliss. Its OK to think this and helps you sleep better. If I were a radiologist, I would rather think this and sleep well believing nothing will change versus a radiology resident who believes they are replaceable wondering what it is going to be like in 5-10 yrs when they start to practice.

Anyone who thinks reading plain film xrays is difficult is WRONG. Anyone who thinks an NP can't be train to read a plain film xray as good or better than a new radiologist attending is WRONG. I am only an ER doc and I can tell you that after 1 yr of ER attending practice, I could read a plain film as well or better than most new attendings and in line with most radiology attendings. Sure, I may not be able to give you 5 differential on a lesion, but I know it is a lesion and need follow up imaging.

Plain film xray readings can easily put to AI or a midlevel, I have no doubt about it.

But we are not talking only about midlevels. There are a slew of issues that will affect all specialists jobs including Rads.

Do you really think surgeons are protected? In the past when a small surgery group had too much work to handle, they would hire another surgeon. Now, they just hire a bunch of APCs to rounds on pts, do D/c instructions, see clinic pts, do call backs, etc. So yeah, an APC can't operate but they can do the other 80% of what a surgeon does and HATE. So yeah, essentially they ARE replacing surgeons. This goes with almost all specialties. Look on the floor and you will see APCs in almost all fields where in the past a doc was hired.

I invest/own FSERs so I actually own my building, own my patients, own my billing, and have a population that will never go back to the hospital ERs. During the pandemic we were seeing 60-90 pts/dy. We get pts sent to us from other doc offices b/c they know we do a better job. But still, I am well aware that I could lose it all tomorrow if carriers stop paying or some gov regulation outlaws FSERs.

Lol. You guys only think about radiology in terms x-rays. Nobody in radiology really cares about them. They are just annoyances to us. The reimbursement is so low. In England, they have these non-physicians called radiographers who read them. It's the cross-sectional studies like CT, US, and MRI that pay the bills and really require the medical knowledge and practical training. You need the complete training of a radiologist to be able to cross-reference the different modalities.

 

[Mount Asclepius]

Clearly missing the big picture of how all of medicine has been and continues to become more so corporatized with midlevel encroachment. Starts with giving up x-rays that don't bill well and you don't care about. I think I've heard this before with easier OR cases, ankle sprains in the ED, and basic hypertension/diabetes care in the outpatient setting. Not going to win over many people in another speciality on their own forum by starting almost all responses with laughing at experienced EPs, not answering direct questions, and telling people repeatedly to go read their old posts, yet while also continuing to engage in new discussion. I think this thread has run its course.

 

[thegenius]

I wonder why we (EM) are arguing so vehemently with our Radiology friends. The exact same thing is being said over and over.

And lastly, I seriously doubt that a non-radiologist can read xrays as good (OR BETTER) than a radiologist, averaged over 100's of xrays.

Anyway this thread is starting to get a little embarrassing that we are telling our fellow doctors in a different field why they should be more scared about the future of their field that we are not in.

 

[Taurus]

I wonder why we (EM) are arguing so vehemently with our Radiology friends. The exact same thing is being said over and over.

And lastly, I seriously doubt that a non-radiologist can read xrays as good (OR BETTER) than a radiologist, averaged over 100's of xrays.

Anyway this thread is starting to get a little embarrassing that we are telling our fellow doctors in a different field why they should be more scared, not less, about the future of their field that we are not in.

I agree. I'm just trying to explain from my perspective as an experienced private practice radiologist why this or that won't work in radiology but you guys don't like my arguments. If you guys were right and I'm wrong, then radiology would be overrun by now with midlevels like many clinical fields like primary care and ED but we're not and won't be in the foreseeable future. It is very rare to have a midlevel reading diagnostic imaging studies, almost nonexistent in private practice. So who's right and who's wrong? The proof is in the pudding as they say. I'm just trying to explain why we have reached this point. Some of you don't like it but it is what it is.

I remember how 10-15 years ago people were declaring the death of radiology because some guy in India was going to read all of the studies. Didn't happen. Why? Because CMS has a rule that requires the radiologist to be on American soil to be reimbursed for final reads. If CMS had changed the rule, then yes, radiology would have been in deep trouble because that's a significant structural change. In the current era of telehealth, it is even more unlikely that rule will ever change. Why? Because if they allow that, most medical fields could be done overseas via videoconferencing. You could staff your hospital with midlevels and have the doctors in India.

Btw, I did say 15 years ago that I thought there were three areas where I could foresee significant midlevel encroachment because I didn't see a large moat separating the physician from the midlevel: primary care, anesthesia, and EM. Unfortunately, my prediction has come true. I've been thinking about this topic for a long time. You guys think I'm new to the midlevel issue or something. Do a search of my posts from 15 years ago.

 

[emergentmd]

Lol. You guys only think about radiology in terms x-rays. Nobody in radiology really cares about them. They are just annoyances to us. The reimbursement is so low. In England, they have these non-physicians called radiographers who read them. It's the cross-sectional studies like CT, US, and MRI that pay the bills and really require the medical knowledge and practical training. You need the complete training of a radiologist to be able to cross-reference the different modalities.

When we were SDGs without APCs we always hired doctors when volume went up. After we started hiring APCS, we stopped hiring docs and had 1 APC for every doctor which is somewhat light. so instead of hiring 2 docs, we hired 3 APCs. So if you think not reading plain films would not decrease demand, then you need to go back to school