Radiology outlook and its challenges.

[shark2000]

Disclaimer: I am a radiologist in pp and really like what I do.

Disclaimer 2: Nobody knows what the future will be like. If you can predict 10 years from now, you are stupid because you are in the wrong field (Medicine). Go into stock market and predict 10 years from now and become a multimillionaire.

These are some statements you hear about radiology. I feel obliged to clarify some of them esp for medical students:

1- Job market: Everybody talks about it. I don't disagree that the job market is not good. But show me a field with a good job market. The only field with good job market is probably Family medicine/IM. Radiology job market is in the middle of specialties. It is better than many and worse than many. If you doubt it, ask ophthalmologists, Derms, plastic surgeons, CT surgeons, Cardiologists, Neurosurgeons, ... about job market.

2- Income: We (medicine in general )are at a challenging point in the history of the medical system. Things are not going in the right way. But, the salary cuts are not specific to radiology. Ask any other field about their cuts. As a pp doctor, no matter whom you talk to you, everybody says that their income is less (much less) than 10 years ago. The orthopod told me that his Knee replacement reimbursement has decreased almost 3 times compared to year 2000. And there is another cut coming for them in 2013.

3- Hours: This is what I agree that radiology has it worse than many other fields. We are working harder than 10 years ago. The main reason is more and more dependence of medical system on imaging. Surgeons had horrible hours 10 years ago and still they have horrible hours. Radiology was a 8-5 job 15 years ago, but it is a 7/24 hospital coverage these days. Still I prefer to read 100-120 studies a nights, than going to OR.

4- Volume: is going up. May not as fast as before. In 2000s we saw 12 % average yearly increase in volume. Now it is stagnant. Since the medical system is dependent on imaging, changes in imaging volume parallel the changes in the whole medical system. If you ask any other field, they confirm stagnant volume also in their field. With Obama-care and increase pool of insured patients we may see increase volume. Also there are tons of technology in line. Bad economy has slowed down technology.

5- Turf issues: Nothing specific to 2013. It was out there since 1950s. In fact, I think at 2013 we are at a better position compared to 90s or 2000s. With more centralization of healthcare in hospitals and also increasing shift of health care from specialists to IM/family medicine, NPs and PAs, I think we will see less and less turf issues. Regarding IR, I think they are in a relatively good position, though whether they take back some control over PAD, I don't know.

6- Long training time: This is right to some extent. But show me a field that does not need sub-specialization. In 21st century, medicine has become so extended that everybody other than Primary care doctors has to go through long training. You can ask Ob-Gyn or surgery residents. Most of them do fellowships of 2-3 years these days after painful long residency.

7- Patient contact: I never ever miss patient contact. It is way way over-rated. There is nothing to miss about seeing demented 80 year old patient with PNA or hear attack. But, if you miss it, you can always do mammo which has a fair amount of patient contact. If you want to sub-merge yourself into it, go to IR. You will see more patients that you can handle.

8- Daily grind of radiology: pp is busy. You work hard. You work for every penny that you earn. But show me any other field that the physicians are not busy or are not working hard. I agree that it can be exhausting, but show me any other physician who leaves the hospital fresh and not exhausted.

At the end of the day, I think radiology was one of the best choices in my life. On the other hand, I can understand that there are people who may not like it. If you like radiology, go for it. Don't let other factors dissuade you from your decision. It is a really satisfying job with a bright future.

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[clownbabyMD]

Thanks for the post, shark2000. As a med student considering Radiology, it's nice to hear these insights.

 

[Cochan]

Thanks for this post! It has a nice positive touch to it while it comes close to Match Week. I have heard similar remarks from other radiologists on rotations!

 

[Elixir86]

Thanks for your honest opinions. As a current IM resident making the switch to Radiology, there have definitely been some days where I ask myself whether I'm making the right choice. Although, looking back on those particular days, I realized I enjoyed those days of IM because they lacked the things I hate the most: little to no admission so no writing worthless pages of H&P, barely getting paged, not having to have much pt contact because everyone was stable, and not dealing with placement or social work issues. Anyways, thanks for the insight.

 

[badasshairday]

Great post. Excited for the future.

 

[shark2000]

Thanks for your honest opinions. As a current IM resident making the switch to Radiology, there have definitely been some days where I ask myself whether I'm making the right choice. Although, looking back on those particular days, I realized I enjoyed those days of IM because they lacked the things I hate the most: little to no admission so no writing worthless pages of H&P, barely getting paged, not having to have much pt contact because everyone was stable, and not dealing with placement or social work issues. Anyways, thanks for the insight.

We had someone in our residency program who did an IM residency before Radiology. He really liked it.

It may or may not work for you, but I think the odds is much much higher that it works.

Patient contact is painful. The order of things in medicine:

Radiology> Derm > outpatient medicine > inpatient medicine > ICU/CCU/ER .

Good Luck

 

[XerxesOfPersia]

As always, love your posts shark.

 

[Elixir86]

We had someone in our residency program who did an IM residency before Radiology. He really liked it.

It may or may not work for you, but I think the odds is much much higher that it works.

Patient contact is painful. The order of things in medicine:

Radiology> Derm > outpatient medicine > inpatient medicine > ICU/CCU/ER .

Good Luck

Thanks man. I'm assuming you meant that your classmate liked Radiology more than his IM Residency. I did a Radiology elective in medical school in the middle of all the interview process, etc. and I really liked it and was kicking myself for not doing the elective sooner. I ended up just sticking with IM as a stepping stone for some specialty. But I realized the way medical students perceive IM is completely different than the realities when you are actually in charge and have to deal with the real aspects of the job. Things I thought I liked about the specialty as a student were completely flipped. Anyways, I hope things work out, too. I'm not doing it for the money or because I think I'll have an easier life. When I compared a future in IM vs Radiology, I realized Rads cut out a lot of things I hated about IM and still kept the things I enjoyed. It's partly my fault for not having more insight into IM beforehand and instead just saying, "Oh well...it's just three years." In any case, I hope everything works out.

 

[bronx43]

We had someone in our residency program who did an IM residency before Radiology. He really liked it.

It may or may not work for you, but I think the odds is much much higher that it works.

Patient contact is painful. The order of things in medicine:

Radiology> Derm > outpatient medicine > inpatient medicine > ICU/CCU/ER .

Good Luck

Can't comment on rads or derm, but as far as the others:

Outpatient > ICU/CCU >> Inpatient >>>>>>>>> ER

Outpatient trumps because of the lifestyle, though I'm including outpatient medicine subspecialties like rheum, allergy, etc. Outpatient general medicine can be tolerable or horrendous depending on your practice. The money sucks too. And ICU over inpatient medicine solely due to the fact that, as you said, patient contact is painful. I rather deal with 20 medical issues than 20 social issues any day of the week and twice on Sunday.

And nothing needs to be said about the ED/dungeon/cesspool/7th circle of Hell.

 

[NappingGuppy]

Thanks much Shark

 

[samsoniter]

SHARK SHARK SHARK SHARK!!!

 

[Leo Aquarius]

...1- Job market: Everybody talks about it. I don't disagree that the job market is not good. But show me a field with a good job market.

Psychiatry.

2- Income: We (medicine in general )are at a challenging point in the history of the medical system. Things are not going in the right way. But, the salary cuts are not specific to radiology. Ask any other field about their cuts.

Avg income for psychiatry has increased over the last 5 years.

6- Long training time: This is right to some extent. But show me a field that does not need sub-specialization.

Psychiatry.

8- Daily grind of radiology: pp is busy. You work hard. You work for every penny that you earn. But show me any other field that the physicians are not busy or are not working hard. I agree that it can be exhausting, but show me any other physician who leaves the hospital fresh and not exhausted.

Psychiatrists.

 

[samsoniter]

You leave the hospital refreshed after a day of psych? I remember being more exhausted after a 6 hour psych day than a 12 hr surgery day....I found it mentally and emotionally exhausting. To generalize, I would guess most people went into rads because of the nature of work, and perhaps to avoid the sometimes cumbersome and frustrating situations that arise in high pt contact specialties. I have always considered myself a people person, but psych seems to be at the opposite end of the spectrum of rads, and due to personal preference, I don't think I could handle psych even if the money was way better and the hours way shorter. I am seriously getting tired just thinking about my psych rotation.

 

[colbgw02]

Nm

 

[qwerty89]

Judging by the NRMP stats from 2012 to 2013

Categorical Internal Medicine spots increased (18%) from 5,277 to 6,277
Family Medicine spots increased (10.8%) from 2,740 to 3,037
Emergency Medicine increased (4.6%) from 1,668 to 1,744
Otolaryngology increased from (2.5%) from 285 to 292
Orthopedic Surgery increased (1.6%) from 682 to 693
Radiology (PGY-2) increased (0.3%) from 976 to 979
Radiation Oncology (PGY-2) increased (2.5%) from 156 to 160
Surgery (Categorical) increased (3.4%) from 1,146 to 1,185
Plastic Surgery (Integrated) increased (14.8%) from 101 to 116

The big jump for IM may be due to the fact that the match was "all-in" this year.

The fact that Radiology spots are growing at a relatively low rate seems like a good thing to prevent future saturation, at least compared to Anesthesiology and EM.

 

[tco]

Psychiatry.



Avg income for psychiatry has increased over the last 5 years.



Psychiatry.



Psychiatrists.

Probably because it's a field made up of unfalsifible hypotheses.

 

[shark2000]

Probably because it's a field made up of unfalsifible hypotheses.

Please...

There is no point in criticizing or belittling what others do. Every field in medicine has its own value. As long as people respect you, they deserve your respect.

A friend of mine who is a neurosurgeon with high high ego told me once that he used to look down at peds doctors, till his lovely child got a leukemia which was managed very good, almost cured. Now he deeply believes that pediatricians are one of the best and most important doctors in the hospital.

Let's grow up.

 

[IamnotFreud]

Please...

There is no point in criticizing or belittling what others do. Every field in medicine has its own value. As long as people respect you, they deserve your respect.

A friend of mine who is a neurosurgeon with high high ego told me once that he used to look down at peds doctors, till his lovely child got a leukemia which was managed very good, almost cured. Now he deeply believes that pediatricians are one of the best and most important doctors in the hospital.

Let's grow up.

That's what one of the peds attendings on here says - that other docs tend to look down on pediatricians... until their kid gets sick, and then they are the most important doctors in the world. Very true. there is a need for all doctors, regardless of specialty.

 

[tco]

Please...

There is no point in criticizing or belittling what others do. Every field in medicine has its own value. As long as people respect you, they deserve your respect.

A friend of mine who is a neurosurgeon with high high ego told me once that he used to look down at peds doctors, till his lovely child got a leukemia which was managed very good, almost cured. Now he deeply believes that pediatricians are one of the best and most important doctors in the hospital.

Let's grow up.

Some people don't know what means, apparently. Perhaps check out the unreasonable "Are Psychiatric Meds BS" allo thread where I defended psychiatrists.

This was my first post in this forum. You don't know me from Adam, so please step down from the soapbox.

Maybe you need to loosen up as much as I need to grow up? Then again, this is the internet...We all know that it's serious business. I'll let you have the last word.

 

[bcovert]

Disclaimer: I am a radiologist in pp and really like what I do.

Disclaimer 2: Nobody knows what the future will be like. If you can predict 10 years from now, you are stupid because you are in the wrong field (Medicine). Go into stock market and predict 10 years from now and become a multimillionaire.

These are some statements you hear about radiology. I feel obliged to clarify some of them esp for medical students:

1- Job market: Everybody talks about it. I don't disagree that the job market is not good. But show me a field with a good job market. The only field with good job market is probably Family medicine/IM. Radiology job market is in the middle of specialties. It is better than many and worse than many. If you doubt it, ask ophthalmologists, Derms, plastic surgeons, CT surgeons, Cardiologists, Neurosurgeons, ... about job market.

2- Income: We (medicine in general )are at a challenging point in the history of the medical system. Things are not going in the right way. But, the salary cuts are not specific to radiology. Ask any other field about their cuts. As a pp doctor, no matter whom you talk to you, everybody says that their income is less (much less) than 10 years ago. The orthopod told me that his Knee replacement reimbursement has decreased almost 3 times compared to year 2000. And there is another cut coming for them in 2013.

3- Hours: This is what I agree that radiology has it worse than many other fields. We are working harder than 10 years ago. The main reason is more and more dependence of medical system on imaging. Surgeons had horrible hours 10 years ago and still they have horrible hours. Radiology was a 8-5 job 15 years ago, but it is a 7/24 hospital coverage these days. Still I prefer to read 100-120 studies a nights, than going to OR.

4- Volume: is going up. May not as fast as before. In 2000s we saw 12 % average yearly increase in volume. Now it is stagnant. Since the medical system is dependent on imaging, changes in imaging volume parallel the changes in the whole medical system. If you ask any other field, they confirm stagnant volume also in their field. With Obama-care and increase pool of insured patients we may see increase volume. Also there are tons of technology in line. Bad economy has slowed down technology.

5- Turf issues: Nothing specific to 2013. It was out there since 1950s. In fact, I think at 2013 we are at a better position compared to 90s or 2000s. With more centralization of healthcare in hospitals and also increasing shift of health care from specialists to IM/family medicine, NPs and PAs, I think we will see less and less turf issues. Regarding IR, I think they are in a relatively good position, though whether they take back some control over PAD, I don't know.

6- Long training time: This is right to some extent. But show me a field that does not need sub-specialization. In 21st century, medicine has become so extended that everybody other than Primary care doctors has to go through long training. You can ask Ob-Gyn or surgery residents. Most of them do fellowships of 2-3 years these days after painful long residency.

7- Patient contact: I never ever miss patient contact. It is way way over-rated. There is nothing to miss about seeing demented 80 year old patient with PNA or hear attack. But, if you miss it, you can always do mammo which has a fair amount of patient contact. If you want to sub-merge yourself into it, go to IR. You will see more patients that you can handle.

8- Daily grind of radiology: pp is busy. You work hard. You work for every penny that you earn. But show me any other field that the physicians are not busy or are not working hard. I agree that it can be exhausting, but show me any other physician who leaves the hospital fresh and not exhausted.

At the end of the day, I think radiology was one of the best choices in my life. On the other hand, I can understand that there are people who may not like it. If you like radiology, go for it. Don't let other factors dissuade you from your decision. It is a really satisfying job with a bright future.

Disclaimer: I am a radiologist in pp and really like what I do.

Disclaimer 2: Nobody knows what the future will be like. If you can predict 10 years from now, you are stupid because you are in the wrong field (Medicine). Go into stock market and predict 10 years from now and become a multimillionaire.

These are some statements you hear about radiology. I feel obliged to clarify some of them esp for medical students:

1- Job market: Everybody talks about it. I don't disagree that the job market is not good. But show me a field with a good job market. The only field with good job market is probably Family medicine/IM. Radiology job market is in the middle of specialties. It is better than many and worse than many. If you doubt it, ask ophthalmologists, Derms, plastic surgeons, CT surgeons, Cardiologists, Neurosurgeons, ... about job market.

2- Income: We (medicine in general )are at a challenging point in the history of the medical system. Things are not going in the right way. But, the salary cuts are not specific to radiology. Ask any other field about their cuts. As a pp doctor, no matter whom you talk to you, everybody says that their income is less (much less) than 10 years ago. The orthopod told me that his Knee replacement reimbursement has decreased almost 3 times compared to year 2000. And there is another cut coming for them in 2013.

3- Hours: This is what I agree that radiology has it worse than many other fields. We are working harder than 10 years ago. The main reason is more and more dependence of medical system on imaging. Surgeons had horrible hours 10 years ago and still they have horrible hours. Radiology was a 8-5 job 15 years ago, but it is a 7/24 hospital coverage these days. Still I prefer to read 100-120 studies a nights, than going to OR.

4- Volume: is going up. May not as fast as before. In 2000s we saw 12 % average yearly increase in volume. Now it is stagnant. Since the medical system is dependent on imaging, changes in imaging volume parallel the changes in the whole medical system. If you ask any other field, they confirm stagnant volume also in their field. With Obama-care and increase pool of insured patients we may see increase volume. Also there are tons of technology in line. Bad economy has slowed down technology.

5- Turf issues: Nothing specific to 2013. It was out there since 1950s. In fact, I think at 2013 we are at a better position compared to 90s or 2000s. With more centralization of healthcare in hospitals and also increasing shift of health care from specialists to IM/family medicine, NPs and PAs, I think we will see less and less turf issues. Regarding IR, I think they are in a relatively good position, though whether they take back some control over PAD, I don't know.

6- Long training time: This is right to some extent. But show me a field that does not need sub-specialization. In 21st century, medicine has become so extended that everybody other than Primary care doctors has to go through long training. You can ask Ob-Gyn or surgery residents. Most of them do fellowships of 2-3 years these days after painful long residency.

7- Patient contact: I never ever miss patient contact. It is way way over-rated. There is nothing to miss about seeing demented 80 year old patient with PNA or hear attack. But, if you miss it, you can always do mammo which has a fair amount of patient contact. If you want to sub-merge yourself into it, go to IR. You will see more patients that you can handle.

8- Daily grind of radiology: pp is busy. You work hard. You work for every penny that you earn. But show me any other field that the physicians are not busy or are not working hard. I agree that it can be exhausting, but show me any other physician who leaves the hospital fresh and not exhausted.

At the end of the day, I think radiology was one of the best choices in my life. On the other hand, I can understand that there are people who may not like it. If you like radiology, go for it. Don't let other factors dissuade you from your decision. It is a really satisfying job with a bright future.

I have been a radiologist for 10 years. I have seen many changes in 10 short years.
When I finished residency teleradiology companies where just starting and PACS was moving to community hospitals. There were many jobs available.
Now there are no jobs and teleradiology has turned the profession into a commodity. What happens to the price of a commodity?
Hospitals churn through radiologists and groups always looking for a better deal. Its as easy as flipping a switch now!
I would not choose this profession again. My wife is a retinal surgeon and although they are getting cut too she can have more stability by having her own practice. This is rare in radiology.
Hospital based physicians have no control or security. A physician should at least have some security!

 

[Patassa]

Dang, post #1 vs #20. Back to zero for me.

 

[foo]

Should residency spots in radiology be reduced?

http://www.auntminnie.com/index.aspx?sec=sup&sub=res&pag=dis&ItemID=106122

 

[EMDO2018]

One thing I don't understand, is how radiologist salaries have been decreasing, but when salary surveys come out there is a 1-2% increase in reimbursement every year.

 

[shark2000]

One thing I don't understand, is how radiologist salaries have been decreasing, but when salary surveys come out there is a 1-2% increase in reimbursement every year.

The starting salaries and the benefits especially years to partnership have definitely changed. I personally don't think the salaries have changed dramatically, but has changed. Even when the market was booming starting salaries in Boston or SF or Chicago was not what people claim. People who take a new job are about 1% of radiologists, so the average may not change.

The crazy high salaries do not exist anymore. It seems that there is more equalization of salaries among groups. Used to be one or two groups in each area who made a fortune and then bunch of other groups making good money. Now it is 5-6 competing groups are doing fine.

Many things have changed DRAMATICALLY. Most of the complaints come from these two things:

1- Availability of jobs: There were tons of 200-250 K jobs in large metro areas in the past. Now there are very few jobs available at all.

2- More equal distribution of studies over 24 hours and over the week. In the last 5-6 years at least in large metro areas radiology has changed into a 24/7 service of everything. MRI used to be only day modality, now most places do it round the clock.

3- More study per radiologist for the same income: I can not feel this because I am new to the field. But older people constantly complain about it.

4- More evening, night and weekend shifts: More and more groups are going toward 24 hour coverage and also as I said above, more and more studies are done during the night.

5- Lack of control over what you read: more and more places are looking for people who are multi task. Read MSK MRI, do barium, do biopsies, do kypho and spine injection, read MRCP, read all PET-CTs and read brain MRs in the weekend shift. Then when the IR guy is on vacation, put all the drains and PICCs.

Bottom line: In academics not that much change. However, the field has changed dramatically in the last 5 years in pp. And people are right about decrease income. For the unit of work that you do, the income has decreased. In the good old days, you could live in a large city, work only during the day and read only MRs in an outpatient imaging center. Now if you want to live in a large city in the same job, you have to take night shifts, work longer hours and read everything. Otherwise, you either can not find a job or you see a big pay cut. As one of my partners said though his salary is the same as before, his REAL SALARY is almost half because if he wants to have the same life style and pace of work as 10 years ago, he has to accept about 50% pay cut.

 

[bcovert]

One thing I don't understand, is how radiologist salaries have been decreasing, but when salary surveys come out there is a 1-2% increase in reimbursement every year.

To understand radiologist salaries you have to know the medicare fee schedule and what type of volume a typical radiologist does. Non con head Cts now pay 40, abd pelvis w/o 90 and non con MR brains pay 75. Most ultrasounds pay 35-40, nucs 30-40 except PET/CT which is 100, x ray 8-10 dollars per study. Interventional is variable but volume is usually small.

Many metro areas have commercial reimbursement less than medicare and medicaid is less in most states. Second and third tier cities are holding on to higher commercial reimbursement- 110-200% of medicare.

Basically many groups are getting 26-30 per study on average and may have average reads of 20,000 exams per rad.

Sum total per rad, 500-600K collections minus 10% for billing, malpractice 15-40K depending on state, (nighthawk in groups that don't cover their own nights can cost 50-100k per rad), miscellaneous expenses around 20K (cme, manager, licensing, dues, etc.)

Therefore many PP groups should be making 350-450K.

There are some crazy outliers making 500-600K in rural areas with good reimbursement ie WY, NE, WI, AK or high volume practices like a few areas in the south or midwest.

 

[shark2000]

There are so many factors that you can not simply make a calculation by multiplying number of studies by pay per study:

1- Uninsured: Depends on where you live. For example, in some Metro areas up to 40% of ED patients may not have insurance. It means that you are not paid for any those studies either brain MRI or CT Perfusion. period.

2- Other insurances: Pay more than medicare, but these days not a lot of patients have good insurances.

3- Repeat exams, insurance paper work, .... : Many times insurance may refuse to pay for many legit or non-legit reasons. The more the insurance representative cut your pay, the more bonus he gets.

4- Hospital employment: Many groups are becoming hospital employees. Pretty much in all employment models, the package starts with FAKE high starting salary to attract people. Probably first or second year you get paid professional fee + 5-10 % of technical fee. Then next year they ask you to cover some more places or read more volume. By the fourth year, esp if the hospital system has monopolized the business in the area, you will get paid 70-80% of your professional fee after deduction of other expenses (Don't get surprised if you get paid half of your collection).

5- Uneven distribution within a group and also between large cities and small places.

6- Paying for other services with less productivity: Some services like IR in most places and low volume mammo in some places are RVU losers. However, a lot of groups HAVE TO provide these services. As a result, they are subsidized services. So you may make X, but it will be redistributed among the group.

7- Night coverage: The same as number 6. As you said if you pay for telerad, you have to pay for it. Many groups are going towards 24/7. If you have your own nighthawk system, even the busiest nights are not as productive as day volume. However, in most groups you get paid around 20% more per hour work at night. In groups that have dedicated night people, they are paid much more per RVU which comes from day people salary.

8- About portables: Xray portable pays around 4-5 and you won't get paid for most followups in the same day. So if there is a morning PNX with 5 other studies the same day, depending on the type of insurance you may get paid 5-6 bucks for the whole 5 studies. Portables are sort of a service that radiology groups have to provide to the hospital as a part of the package. Also there is a lot of doubt whether we add any value to the patient care by reading morning portables. However, since it is a low pay study and at the same time not time consuming, both radiology and ICU physicians are just silent about it and prefer to keep it as it is.

 

[bcovert]

There are so many factors that you can not simply make a calculation by multiplying number of studies by pay per study:

1- Uninsured: Depends on where you live. For example, in some Metro areas up to 40% of ED patients may not have insurance. It means that you are not paid for any those studies either brain MRI or CT Perfusion. period.

2- Other insurances: Pay more than medicare, but these days not a lot of patients have good insurances.

3- Repeat exams, insurance paper work, .... : Many times insurance may refuse to pay for many legit or non-legit reasons. The more the insurance representative cut your pay, the more bonus he gets.

4- Hospital employment: Many groups are becoming hospital employees. Pretty much in all employment models, the package starts with FAKE high starting salary to attract people. Probably first or second year you get paid professional fee + 5-10 % of technical fee. Then next year they ask you to cover some more places or read more volume. By the fourth year, esp if the hospital system has monopolized the business in the area, you will get paid 70-80% of your professional fee after deduction of other expenses (Don't get surprised if you get paid half of your collection).

5- Uneven distribution within a group and also between large cities and small places.

6- Paying for other services with less productivity: Some services like IR in most places and low volume mammo in some places are RVU losers. However, a lot of groups HAVE TO provide these services. As a result, they are subsidized services. So you may make X, but it will be redistributed among the group.

7- Night coverage: The same as number 6. As you said if you pay for telerad, you have to pay for it. Many groups are going towards 24/7. If you have your own nighthawk system, even the busiest nights are not as productive as day volume. However, in most groups you get paid around 20% more per hour work at night. In groups that have dedicated night people, they are paid much more per RVU which comes from day people salary.

8- About portables: Xray portable pays around 4-5 and you won't get paid for most followups in the same day. So if there is a morning PNX with 5 other studies the same day, depending on the type of insurance you may get paid 5-6 bucks for the whole 5 studies. Portables are sort of a service that radiology groups have to provide to the hospital as a part of the package. Also there is a lot of doubt whether we add any value to the patient care by reading morning portables. However, since it is a low pay study and at the same time not time consuming, both radiology and ICU physicians are just silent about it and prefer to keep it as it is.

 

[bcovert]

Shark2000, You can evaluate a practice based on average reimbursement per exam. MMP and Mckesson both provide this data. If you become a partner one day you will see it.

I agree with most of the above.

Repeat exams can be billed with a -59 modifier and be reimbursed. Portables are paid as one view chest 71010 $9.38.

Private practice is better than hospital employment which is better than predatory national radiology groups like radisphere, onrad, 24/7 rad, blah blah....

 

[shark2000]

Shark2000, You can evaluate a practice based on average reimbursement per exam. MMP and Mckesson both provide this data. If you become a partner one day you will see it.

I agree with most of the above.

Repeat exams can be billed with a -59 modifier and be reimbursed. Portables are paid as one view chest 71010 $9.38.

Private practice is better than hospital employment which is better than predatory national radiology groups like radisphere, onrad, 24/7 rad, blah blah....

Thanks for your information.

 

[colbgw02]

If you become a partner one day you will see it.

 

[shark2000]

hahahaha, I didn't make any assumptions or conclusions. Anyway, I have become a partner. Was relatively fast track for me, esp in today's market.

 

[NonTradJp]

Thank you for this post. It's from a couple of years ago and it was a very interesting read.

 

[calhigheric]

hi shark2000 i have a project and require a interview i wanted to know if i can ask you some question about the field of a radiologist thank you for your time

 

[calhigheric]

hahahaha, I didn't make any assumptions or conclusions. Anyway, I have become a partner. Was relatively fast track for me, esp in today's market.

hi shark2000 i have a project and require a interview i wanted to know if i can ask you some question about the field of a radiologist thank you for your time i will very much appreciate it

 

[shark2000]

hi shark2000 i have a project and require a interview i wanted to know if i can ask you some question about the field of a radiologist thank you for your time

PM me.

 

[FranzLO]

This is a specific question, and I was not sure where to ask it, but in regards to salaries and what not, if a radiologist takes a one week on/two weeks off model, is there salary still usually good or fair and are they working much less hours for this? Just trying to wrap my head around this option I see a lot. I would prefer to never to do this, but I am curious about how it works in regards to salaries and hours.

 

[colbgw02]

This is a specific question, and I was not sure where to ask it, but in regards to salaries and what not, if a radiologist takes a one week on/two weeks off model, is there salary still usually good or fair and are they working much less hours for this? Just trying to wrap my head around this option I see a lot. I would prefer to never to do this, but I am curious about how it works in regards to salaries and hours.

To be clear, you're referencing in-house night radiologists. And the answer to your question is yes - the per hour salary is usually higher for these positions, but your overall compensation is usually lower because fewer total hours are being worked. This is especially true for the 1-on/2-off model you mentioned.

On a related note, the burnout rate for these positions is notoriously high. Although it is worse for 1-on/1-off model, even the 1-on/2-off model results in relatively high turnover.

 

[fun8stuff]

This is a specific question, and I was not sure where to ask it, but in regards to salaries and what not, if a radiologist takes a one week on/two weeks off model, is there salary still usually good or fair and are they working much less hours for this? Just trying to wrap my head around this option I see a lot. I would prefer to never to do this, but I am curious about how it works in regards to salaries and hours.

The 1 week on/ 2 week off gigs usually pay similar to starting salary for private practice or a little more (about average pay) for about 40-50% less hours. These gigs are usually only available in bigger health systems who can afford to subsidize the night shifts. Private practices generally cannot afford to make this model work.

It's not as good as it may first seem though. Most are 12 hr grueling shifts. Switching your awake hours is harder than you think... And you will have to continuously make the switch. If you want to do anything- family /friend events, haircuts, maintenance, haircuts, doc appointments, banking, shopping ... Any kind of life at all, etc all have to be during the day. You are going to lose a few days switching and you won't be on your A game for the first couple nights of your grueling week. You still work 1/3 of all weekends.... More than 1 weekend per month. Additionally, you won't have the chance to make partner or advance your position within the group. Your procedural and advanced imaging skills will atrophy making you less attractive to ever do any other type of job than ER nights.

I was considering a 1 on/2 off position... And almost took the job, but a couple people who had or were doing it convinced me otherwise.

 

[shark2000]

The 1 week on/ 2 week off gigs usually pay similar to starting salary for private practice or a little more (about average pay) for about 40-50% less hours. These gigs are usually only available in bigger health systems who can afford to subsidize the night shifts. Private practices generally cannot afford to make this model work.

It's not as good as it may first seem though. Most are 12 hr grueling shifts. Switching your awake hours is harder than you think... And you will have to continuously make the switch. If you want to do anything- family /friend events, haircuts, maintenance, haircuts, doc appointments, banking, shopping ... Any kind of life at all, etc all have to be during the day. You are going to lose a few days switching and you won't be on your A game for the first couple nights of your grueling week. You still work 1/3 of all weekends.... More than 1 weekend per month. Additionally, you won't have the chance to make partner or advance your position within the group. Your procedural and advanced imaging skills will atrophy making you less attractive to ever do any other type of job than ER nights.

I was considering a 1 on/2 off position... And almost took the job, but a couple people who had or were doing it convinced me otherwise.

Well Said.

Esp the last part is very important. Changing jobs will be difficult thereafter. MRI volume is usually not high during the night and most cases are stroke or acute cord syndrome from ED. CT, US and plain film volume is high, but again most cases are emergent cases like trauma or acute abdomen or PE from ED. You won't do oncology imaging which is a big part of radiology. As the above poster mentioned, you won't be doing high end imaging, challenging pathologies, procedures, ....

The only advantages of a night job are: 1. Better pay/hour 2. less BS phone calls and interruptions during the nights

Some people who normally sleep at 3 am and wake up at 11am may like the hours. Usually these people hate to wake up 6 or 7 am to go to work and a night job well fits their sleep-wake cycle.

As a first job, a night job is a very bad idea.

 

[FranzLO]

Yeah

Well Said.

Esp the last part is very important. Changing jobs will be difficult thereafter. MRI volume is usually not high during the night and most cases are stroke or acute cord syndrome from ED. CT, US and plain film volume is high, but again most cases are emergent cases like trauma or acute abdomen or PE from ED. You won't do oncology imaging which is a big part of radiology. As the above poster mentioned, you won't be doing high end imaging, challenging pathologies, procedures, ....

The only advantages of a night job are: 1. Better pay/hour 2. less BS phone calls and interruptions during the nights

Some people who normally sleep at 3 am and wake up at 11am may like the hours. Usually these people hate to wake up 6 or 7 am to go to work and a night job well fits their sleep-wake cycle.

As a first job, a night job is a very bad idea.

Yeah it sounds like the kind of job that is taken in order to compromise for something like location, salary, etc. I assume there are plenty of normal day jobs out there. My wife will also be a physician so people are telling me to try and get a slower paced job in academics or at a VA since we should be fine salary-wise. However, I have heard these are competitive. I know this can always come off poorly so hopefully it doesn't but how rare is it to find a more relaxed radiology job with a sacrifice in pay? It sounds like this would be very rare but I was curious about those circumstances.

 

[colbgw02]

Relaxed private practice jobs are few and far between now, and even many academic jobs are a lot busier than they used to be. Some practices are considered "lifestyle" groups, but even that is relative and can mean different things. Sometimes that just means the group is structured to give more vacation time, but the day-to-day work is still extremely busy. Sometimes a practice gets labeled as a lifestyle group only because it's not quite as busy as a nearby group, but the overall workload is still substantial.

 

[scootad.]

I think it's fair to say that nothing is free these days. I work in a rare M-F 8-5 pm outpatient job with no call, nights or weekends. But its pretty damn busy, high volume when I am at work. I routinely read over 100 exams/day (50 x rays/25 MRI and CT/20 US/15 Mammo). It's definitely not a walk in the park. I don't mind because I read very fast anyway. But I've seen people crash and burn with high volumes especially people who have long-winded, wordy reports. VA (and possibly Kaiser) may be the only chill/low volume jobs around these days.

 

[shark2000]

Relaxed private practice jobs are few and far between now, and even many academic jobs are a lot busier than they used to be. Some practices are considered "lifestyle" groups, but even that is relative and can mean different things. Sometimes that just means the group is structured to give more vacation time, but the day-to-day work is still extremely busy. Sometimes a practice gets labeled as a lifestyle group only because it's not quite as busy as a nearby group, but the overall workload is still substantial.

Agreed.

Most private practice groups work at a fast pace. And by fast I mean many more studies per hour compared to even the busiest day of residency or fellowship. Residents, fellows and academic faculty may think that their days are very busy. I did my training in a busy academic center and right now my volume in private practice is at least 2 times more than the busiest day in my fellowship.

In pp radiology more productivity per hour, more vacation time, less weekend calls and less overnight calls are the priorities. The pace of work not that much. As a result the practice has become crazy fast in most places.

Finding a VA job, academic job or Kaiser type job is not easy. It has become difficult. It needs connections and luck. These are not necessarily the places that most private practice radiologists like to work. However, still the number of people who like these places are more than the number of spots available.

Academic is its own environment. You may require to do research or lots of other things that you don't like. VA and Kaiser are not for everyone. You have to be able to tolerate a lot of bureaucracy in these places.

On the other hand, private practice is not for everyone. Some people can not keep up with the speed. We had one person in the past who quit after his first few months, despite being a good radiologist. Some people also can not tolerate the grind of private practice in the long run. These are the people who quit their job for a slower one after 4-5 years in pp.

This is not a life-style field anymore. Private practice radiology is way different than what medical students think. People won't realize it until they are in fellowship moonlighting or they are in their first private practice job.

 

[meister]

Man, you are really lucky if the only MRI at night is stroke/cord compression and they don't scan metastatic work-ups at 4AM...

 

[DrBowtie]

Man, you are really lucky if the only MRI at night is stroke/cord compression and they don't scan metastatic work-ups at 4AM...

That is not an appropriate call case to read at 4 am for a trainee.

 

[vm26]

Disclaimer: I am a radiologist in pp and really like what I do.

2- Income: We (medicine in general )are at a challenging point in the history of the medical system. Things are not going in the right way. But, the salary cuts are not specific to radiology. Ask any other field about their cuts. As a pp doctor, no matter whom you talk to you, everybody says that their income is less (much less) than 10 years ago. The orthopod told me that his Knee replacement reimbursement has decreased almost 3 times compared to year 2000. And there is another cut coming for them in 2013.

Income is less but don't think it's that drastic, we are just working significantly longer/harder. A 30% reimbursement cut is buffered by becoming more efficient (obviously there is a limit). One of my former attending rads who came out in mid 90's started out in pp at around 50% of what is typical now and the partners in his group made little more than typical starting salaries today. To be fair they were in a saturated market (Tri-state) but I think many in medicine over-glorify the past. When I was 1st looking into going to med school in the early 90's, the docs that I spoke with basically said that from a financial standpoint the ship had already sailed. However I do know that many docs did extremely well during the past 2 decades so guess it is all about perspective and what the status quo is

 

[shark2000]

Income is less but don't think it's that drastic, we are just working significantly longer/harder. A 30% reimbursement cut is buffered by becoming more efficient (obviously there is a limit). One of my former attending rads who came out in mid 90's started out in pp at around 50% of what is typical now and the partners in his group made little more than typical starting salaries today. To be fair they were in a saturated market (Tri-state) but I think many in medicine over-glorify the past. When I was 1st looking into going to med school in the early 90's, the docs that I spoke with basically said that from a financial standpoint the ship had already sailed. However I do know that many docs did extremely well during the past 2 decades so guess it is all about perspective and what the status quo is

Agree.

Income is slightly less, but for the unit of work it is much less. As you mentioned, groups have adjusted to it by becoming more efficient and have managed to keep the salaries high. However, there are two unintentional consequences:
1. Tight job market: Right now two radiologists are doing the work that used to be done by three.
2- Getting burnt out: An internist now can make more than 20 years ago by becoming a hospitalist. However, he is managing 2 times more patients. The same for radiology. Our volume probably has doubled and we work longer hours with fast pace.

Having said that, I agree with your point. Even in the glory days of radiology, the crazy high salaries that people talk about did not exist in Tri-state. Someone knew someone in a remote town that had a solo practice and used to make a bank. My partners told me that they used to make about 15% more in the glory days of radiology, nothing more.

People tend to exaggerate the old good days. In 90s also people probably were talking about good old days in 60s.

With a doctor's salary, you can have a comfortable life. If not, there is something wrong with how you spend the money.

Most doctors that made a bank in the last 20 years, made it through other income revenues. The booming stock market in early 2000s made some people rich. The booming house market before 2007, made some other rich. Some also got rich by having a wise financial plan.

Someone who can make 200-250K+ (most physicians can), should not really have financial problems in the long run.

 

[fun8stuff]

Agreed.

Most private practice groups work at a fast pace. And by fast I mean many more studies per hour compared to even the busiest day of residency or fellowship. Residents, fellows and academic faculty may think that their days are very busy. I did my training in a busy academic center and right now my volume in private practice is at least 2 times more than the busiest day in my fellowship.

In pp radiology more productivity per hour, more vacation time, less weekend calls and less overnight calls are the priorities. The pace of work not that much. As a result the practice has become crazy fast in most places.

Finding a VA job, academic job or Kaiser type job is not easy. It has become difficult. It needs connections and luck. These are not necessarily the places that most private practice radiologists like to work. However, still the number of people who like these places are more than the number of spots available.

Academic is its own environment. You may require to do research or lots of other things that you don't like. VA and Kaiser are not for everyone. You have to be able to tolerate a lot of bureaucracy in these places.

On the other hand, private practice is not for everyone. Some people can not keep up with the speed. We had one person in the past who quit after his first few months, despite being a good radiologist. Some people also can not tolerate the grind of private practice in the long run. These are the people who quit their job for a slower one after 4-5 years in pp.

This is not a life-style field anymore. Private practice radiology is way different than what medical students think. People won't realize it until they are in fellowship moonlighting or they are in their first private practice job.

People always say the volume is so much higher in PP, but I feel like I'm held back in fellowship and residency because staffing out more than doubles time it takes to get through a study, especially if you get stuck with an old or OCD attending who takes forever to staff out with. When i moonlight I routinely get through 2 what I do in fellowship, but I think that's mostly just because I don't have to staff out or deal with the typical scut work. I guess I'm just looking for reassurance as I'll be starting my real job very shortly now! I feel very busy as a fellow, but a different kinda of busy as when I'm moonlighting.

But I completely agree- I never understood as a med student how busy Radiology is. There's no downtime. It's a grind.

 

[svst02]

Disclaimer: I am a radiologist in pp and really like what I do.

Disclaimer 2: Nobody knows what the future will be like. If you can predict 10 years from now, you are stupid because you are in the wrong field (Medicine). Go into stock market and predict 10 years from now and become a multimillionaire.

These are some statements you hear about radiology. I feel obliged to clarify some of them esp for medical students:

1- Job market: Everybody talks about it. I don't disagree that the job market is not good. But show me a field with a good job market. The only field with good job market is probably Family medicine/IM. Radiology job market is in the middle of specialties. It is better than many and worse than many. If you doubt it, ask ophthalmologists, Derms, plastic surgeons, CT surgeons, Cardiologists, Neurosurgeons, ... about job market.

2- Income: We (medicine in general )are at a challenging point in the history of the medical system. Things are not going in the right way. But, the salary cuts are not specific to radiology. Ask any other field about their cuts. As a pp doctor, no matter whom you talk to you, everybody says that their income is less (much less) than 10 years ago. The orthopod told me that his Knee replacement reimbursement has decreased almost 3 times compared to year 2000. And there is another cut coming for them in 2013.

3- Hours: This is what I agree that radiology has it worse than many other fields. We are working harder than 10 years ago. The main reason is more and more dependence of medical system on imaging. Surgeons had horrible hours 10 years ago and still they have horrible hours. Radiology was a 8-5 job 15 years ago, but it is a 7/24 hospital coverage these days. Still I prefer to read 100-120 studies a nights, than going to OR.

4- Volume: is going up. May not as fast as before. In 2000s we saw 12 % average yearly increase in volume. Now it is stagnant. Since the medical system is dependent on imaging, changes in imaging volume parallel the changes in the whole medical system. If you ask any other field, they confirm stagnant volume also in their field. With Obama-care and increase pool of insured patients we may see increase volume. Also there are tons of technology in line. Bad economy has slowed down technology.

5- Turf issues: Nothing specific to 2013. It was out there since 1950s. In fact, I think at 2013 we are at a better position compared to 90s or 2000s. With more centralization of healthcare in hospitals and also increasing shift of health care from specialists to IM/family medicine, NPs and PAs, I think we will see less and less turf issues. Regarding IR, I think they are in a relatively good position, though whether they take back some control over PAD, I don't know.

6- Long training time: This is right to some extent. But show me a field that does not need sub-specialization. In 21st century, medicine has become so extended that everybody other than Primary care doctors has to go through long training. You can ask Ob-Gyn or surgery residents. Most of them do fellowships of 2-3 years these days after painful long residency.

7- Patient contact: I never ever miss patient contact. It is way way over-rated. There is nothing to miss about seeing demented 80 year old patient with PNA or hear attack. But, if you miss it, you can always do mammo which has a fair amount of patient contact. If you want to sub-merge yourself into it, go to IR. You will see more patients that you can handle.

8- Daily grind of radiology: pp is busy. You work hard. You work for every penny that you earn. But show me any other field that the physicians are not busy or are not working hard. I agree that it can be exhausting, but show me any other physician who leaves the hospital fresh and not exhausted.

At the end of the day, I think radiology was one of the best choices in my life. On the other hand, I can understand that there are people who may not like it. If you like radiology, go for it. Don't let other factors dissuade you from your decision. It is a really satisfying job with a bright future.

I wish Radiology was really not falling apart. It is such an interesting specialty.

Read it today on Diagnostic Imaging:
Radiologists Are Burning Out
June 04, 2015 | Practice Management, PACS and Informatics
By Loren Bonner

Radiologists are among the top 10 most burned out physicians, according to Medscape’s 2015 Physician Lifestyle Report. In seventh place—right behind internal medicine, general surgery, and infectious diseases—the report found that 49% of radiologists felt burned out. The figure is a significant increase from last year’s Physician Lifestyle Report, where radiology ranked low on the list at number 18.


Although it’s difficult to predict who might be at risk, radiologists are not immune to burnout despite radiology’s reputation as a lifestyle specialty. And if the Medscape 2015 Physician Lifestyle Report is any indication, it’s an issue that is bubbling to the surface at a rapid clip.

“Unique aspects of our profession, such as its relatively isolated and sedentary nature, might predispose some radiologists to burnout,” said Michael F. McNeeley, MD, a fellow in the University of Washington’s department of radiology.

The Medscape report defines burnout as a loss of enthusiasm for work, feelings of cynicism, and a low sense of personal accomplishment.

Isolation—Never an Effective Model
"You can’t chop away in a room just reading images without losing interest in what you are doing,” said John Cronan, MD, chairman of the department of diagnostic imaging at Brown University’s Alpert Medical School and radiologist-in-chief at Rhode Island Hospital.

Isolation was never an issue for radiologists before PACS. In fact, during the days of film, the radiology department was one of the busiest places in a hospital. Today, however, most radiologists read studies in isolated cubicles. This isolation has been synchronized with decreased reimbursement as well, according to Cronan.

“We are motivated to read more and take advantage of not being interrupted by other doctors,” said Cronan. “Thinking that was good, it has led to total isolation, deprivation and radiologists becoming burned out.”Cronan calls it the efficiency model.
Although PACS has led to many positive gains for radiology and medicine as a whole, at the same time, it has left radiologists with diminished support, fewer professional relationships, and feelings of isolation and loneliness.
At Rhode Island Hospital, Cronan came up with a simple intervention to help try to alleviate the problem.
“We weren’t going to get the referring physicians back but we could cluster the doctors and radiologists together in an open room,” said Cronan.
They started small by breaking down a wall that separated the reading stations of body CT and body ultrasound. Now it’s one big room they call the body room.
“Some interchange and socialization during the day has been huge,” said Cronan.
At the same time, the hospital’s emergency department needed to increase its capacity. Instead of having another radiologist help read ER studies in a different location, Cronan suggested physically putting the attending physicians and residents in the ER together, which has also been successful, especially among radiologists who would rather avoid ER rotations because of the isolation.
Most recently under Cronan’s direction, Rhode Island Hospital has combined diagnostic and screening mammography radiologists in the same room, as well as neurology and spine MR.
“I have come to the conclusion that we have a higher job satisfaction when people work together—and they like working together as a team,” said Cronan.

Contributing Factors
According to the 2014 American Medical Group Association (AMGA) 27th Annual Medical Group Compensation and Financial Survey, which was also discussed at RSNA 2014, relative value unit (RVU) increased at an even higher rate than compensation for radiologists. RVU rates, which are the primary measure of a physician’s productivity, set reimbursement by the Centers for Medicare and Medicaid Services (CMS).

The study found that RVUs for interventional radiologists increased by 5.8% and by 7.2% for diagnostic radiologists. According to RSNA, the rise represents one of the highest in any specialty, except for psychiatry.

Coupled with this are changes to the Multiple Procedure Payment Reduction (MPPR) as applied to RVUs. In 2012, when CMS expanded MPPR to include a cut to the professional component, RVUs should have been reduced too, since an additional second study only gets credited for 50% of the RVUs as opposed to 100%. Notably higher RVUs—when the MPPR should have made them lower—signifies radiologists are working even harder.

Of all the factors that could be contributing to burnout among radiologists, the increase in work volume may be the overriding factor, according to Peter Moskowitz, MD, a clinical professor of radiology at Stanford University School of Medicine.

“It seems every year that the number of cases and the daily work volume seems to be getting greater at a time when there is pressure to increase individual work productivity,” said Moskowitz.

He says radiologists’ RVUs are being monitored to the point where some hospital administrators are using RVU output to determine salary and bonuses.

“There is tremendous pressure on radiologists to work more and do it faster and that stress is the major problem,” said Moskowitz.

Without interventions, he said it’s hard to see the situation improving.

Who Might Be Impacted the Most
Moskowitz, who is also founder and executive director of the Center for Professional and Personal Renewal where he coaches physicians on career and life management, said in his 16 years of coaching, radiologists have become his predominant client over the past five years or so.

“It’s becoming more and more of a problem in our field,” he said.

Yet at the same time, he said it’s still the elephant in the room that no one wants to acknowledge. He said the anxiety and depression radiology trainees feel is often not spoken about because many are reluctant to admit they need help in the first place.

Moskowitz cites a particularly high stress rate among radiology trainees, which he has noticed first-hand in many of his radiology residents.

“Burnout is becoming more of a significant issue among trainees in radiology, and if left unaddressed, the natural progression would be that it would start affecting their mood and performance,” said Moskowitz.

McNeeley and his colleagues were the first to look at burnout for radiology trainees. Based on a 2013 study, they found similar levels of burnout among radiologists when compared to internal medicine residents. This correlation signifies something noteworthy because for years radiology has carried a reputation for being a lifestyle specialty.

McNeeley said this could end up misguiding medical students to enter the field for the wrong reasons and perhaps with unreasonable expectations. By the same token, he said it could cause department leaders to underestimate the pressures that their trainees are experiencing and possibly result in a lack of department wellness initiatives that should be in place.

This current situation seems especially worrisome and stressful for radiology trainees. Radiology residents work nights and weekends, take frequent calls, and are not in a position of power, according to Moskowitz.

In addition, they go through a relatively long training period—which includes five years of postgraduate training with fellowships becoming virtually obligatory; they are hit with medical student debt that can easily exceed $150,000 as they begin residency coupled with difficulty finding affordable housing in urban centers when they begin training; and they face an uncertain job market as well as changes in the board certification process.

Moskowitz said those who are single and without the added income from a working spouse are especially susceptible to such financial stress.

“Over time, this financial stress takes a toll,” said Moskowitz.

Both McNeeley and Moskowitz agree that if the topic is not addressed and conditions are not improved, radiology could face a recruitment crisis in the years to come.

Moskowitz said leaders should be concerned if they begin to see residents leaving their training programs before completion.

“It’s a huge issue of tremendous importance—it threatens the very viability of radiology,” he said

- See more at: http://www.diagnosticimaging.com/pr...rememberme=1&ts=05062015#sthash.0XUmThTx.dpuf

 

[meister]

Well that's a depressing article. You would think the market would be booming considering our services have never been more in demand but it's amazing how reimbursement cuts more than nullify that fact.