Rads vs. Cards

[brandonite]

Hi all.

I'm almost at my end of my first year of medical school, and so far, radiology and cardiology have jumped out at me as possible residency choices. I know it's early, but my school recommends that we have a residency choice in mind by late second year so we can schedule our clerkship in the best possible way.

So, I was hoping to pick your collective brains about radiology. I have an honours degree in Physics/Math, and I have a lot of research in radiology. Last summer, I was working on shimming and calibrating a 3T head-only MRI, and for the next two summers, I'm working on a fMRI study on autism. I'm near the top of my class, and my school has a large diagnostic rads program that they tend to recruit locally from, so I don't think I'll have too hard a time getting matched to rads. On the other hand, getting into cardiology might be a lot harder, and I wouldn't know my chances until part way through my IM residency (and I do know I don't want to become an internist....).

Anyway, I'm wondering about a few specific areas...

1. Monotony... I actually find looking at CXR's and CT's interesting, which makes me unique amongst my classmates. But I'm worried that after a few years of doing nothing but looking at CT's and CXR's, it might start to get boring. I like the idea of doing some interventional to break up the day, but is this something I should be worried about? Is it normal for one radiologist to look at all different imaging modalities, or do you specialize in just a couple? I've noticed at the hospitals that I've seen, most cardiologists seem to have a specialty area. I think I would get bored if I did nothing but look at mammography films for the 25 years or so I'll practice.

I realize this is a problem with cardiology (coronary artery disease, over and over...), but I think the patient contact might help to break it up a bit.

Any comments?

2. Control... One of the things that I've really liked is the ability to take information, put it all together, and come up with a diagnosis. I think that you end up doing that same sort of things with radiology, so I'm not too worried about that. But as a final part of this whole problem solving process, I like that I can plan out a treatment plan. Do any of you miss this in radiology? You get to make the diagnosis a lot of the time, but then you hand it off to another doctor to follow through with. Unless I'm missing something.

3. Patient contact... I know radiology means a lot less patient contact than cardiology. To be honest, I don't know if this is a good thing or a bad thing right now. I don't mind being around patients, at least right now, but this could change with time. But are there areas of radiology (I'm thinking interventional...) that allow you to have more contact? It's nice to know that the option is open to you.

4. The future... I've read over a lot of the topics on this forum, and I'm getting the impression that the future of radiology is a bit more in doubt than other areas (the thread about India, dropping renumeration, etc...). How much of this should I be worried about, and how much of this is just people fearmongering?

To be honest, I'm not too concerned about the lifestyle. I'm young (only 23), and I don't mind working long days. I know that cardiology would mean a lot more hours, especially during the residency. I don't have a lot of student loans, and I'm used to living on a student's budget, so both radiology and cardiology make more money than I know what to do with right now, so I don't are about that.

I'm not looking to make a decision anytime soon, obviously. But I just want a bit more information from people who are actually in the area right now. I am going to do some job shadowing over the next year, and then hopefully I can do clerkships in both before I need to get too worried about the match and my final choices. I'm also considering an MD/PhD, and I need to decide for certain on that by the end of my second year. This isn't a huge problem - the lab I'm working at does a lot of cardiac imaging, so I could just do a project in that area and cover myself for either specialty, but still...

I don't mean to sound like I have a lot of reservations about rads - I find it fascinating... I was amazed when I saw my first echo, and like I said, I like the way that a CXR or a CT is a bit of a problem solving exercise. I have this many, if not more, reservations about cardiology, but the cardiologists at my school are much more open and easy to talk to about this sort of thing than the radiologists, so I'm sorta stuck.

Thanks!

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[GeneralTso]

You know cards is a IM fellowship so your choices are not apples to apples. Its more like Rads vs top 10 IM program.

I was keen on becoming a cardioligist prior to going to med school but then i learned you had to go through several years of IM and then that desire went kaput. I would have to disagree with you on specialty selection based on lifestyle. Its all about the lifestyle.

 

[lrg]

Well, IMHO you have narrowed it down to the two best specialties, so congratulations. For background, I started med school planning to go into surgery but found the act of dissecting in anatomy lab so mind-numbingly boring that I knew surgery wasn't for me (but I loved to subject matter). After looking into some other fields I quickly came to the conclusion that cards or rads were the fields for me. I was leaning more towards cards on entering my third year but it only took a couple months of medicine to convince me to go the rads route. In response to some of your specific points:

1. Monotony - As a radiologist you have the option of specializing in one modality (or more often body system) or being a true generalist. If it's your thing, you could do general radiology and read everything from head to toe. In my mind it is less monotonous than seeing yet another case of CHF or AFib. A gas resident once told me that any field is going to become boring after about 10 years, so there is no reason killing yourself doing something like neurosurg or cards. Maybe he was just rationalizing going into one of the most boring fields but there is probably some truth to it.

2. Control - You have stumbled onto one of the greatest things about radiology, though you present it as a negative. The follow-thru of treatment (at least medical as opposed to surgical treatment) is tedious. Personally, I find surgical treatment to be tedious as well but less so. You have to write the order, check back and make sure the nurse did it, then wait and see if things get better. In the mean time you are getting paged because the patient has a potassium on 3.4 or their crazy family members want to talk to you or they are feeling dizzy. Now multiply that by the 6-14 patients you are carrying. Leaving those kinds of details to someone else while you do the higher-level decision making (diagnosis and occasional treatment recommendations) is a major selling point for rads. Although the clinician is (or should be) responsible for coming up with a treatment plan I was surprised at how often they asked the radiologist what they should do. Many clinicians have become almost completely depedent on imaging and the radiologist interpretation when deciding patient management.

3. Patient contact - Patient contact is WAY overrated. Don't believe me now, I didn't believe it when I was in your position. Just file that statement away and reassess it after your third year. That said, you are correct that you can get all the patient contact you want in interventional or almost none at all if you prefer. Some people describe radiologists as doctor's doctors. Going back to the monotony issue, you will be interrupted repeatedly by docs coming in to review films with you. You get plenty of human contact.

4. Future - You can't predict the future, period. There are threats to radiology, including third-world interpretations for pennies on the dollar and specialists reading (and billing for) their own studies. Rads has always been a relatively well remunerated specialty and I don't expect that to change. There is always some new technology coming out that insurance companies will reimburse well for just because it's new. The future is not something I am overly concerned about.

5. Lifestyle - Medical students tend to underrate lifestyle as much as they overrate patient contact when it comes to deciding on a specialty. When you get into the hospital, take a good look at how happy the attendings are. At my hospital the cards attendings were all burnt out while the rads attendings were loving life.

6. MD/PhD - NO NO NO! Unless you are 100% certain you want to do 100% research, don't do it. There are plenty of MDs out there doing research. I have met too many residents who are pissed that they wasted those years doing a PhD. You are young now but it seems time catches up fast in your mid twenties and you start to feel old and wish you were done with this endless training. It is a long enough road as it is without adding on more years.

One thing I wouldn't worry about is not getting into a cards fellowship following IM residency. There are plenty of fellowships out there and although it is relatively competitive, the kind of person who is at the top of their class and can produce some research will (a) get into a top IM program and (b) get into at least a decent cards fellowship. A key point is that you will need to do an IM residency, which (for me) would be unbearable. I figured why spend three years doing something I hated when I could get started right away with rads (following a transitional internship).

 

[oldandtired]

I think lrg is dead on and agree with him completely! I had many of the same concerns when I was a medical student. Now I am amused at my naivete.

 

[MacGyver]

radiology has a unique challenge in the future.

Rads faces a HUGE threat of outsourcing. Its very easy to outsource digital data over the internet to other countries, therefore radiologists are replaceable globally like no other specialty.

there's also continuous pressure from other doctors to interpret their own films. Right now they havent made much progress in that area, but who knows what will happen in the future.

Cardiology protects its turf better than rads does

 

[eddieberetta]

Radiology is a fascinating and diverse specialty. However it is not for everyone. The most important factor is you -- how much do you love the job. The best way to decide is to experience it yourself. If you choose rads, make sure you like the bread and butter (DR-body imaging) as it will form the majority of your residency. If you choose IM-cards, make sure you like wards and clinics. Choose what you like the most, but don't let it tear you up either -- I am sure you, like most smart people, can find a satisfactory niche in either specialty.

Also remember, other specialties have turf wars (In IM, for e.g., it will be with non-MD providers). Teleradiology is going through a credentialing hiccup right now that will be long sorted out by the time you enter practice (even now, a BC radiologist signs every report-- the issue of whether to accept foreign non BC'd specialists impacts every specialty).

Do not let fear-mongering on this board influence your choice of career.

 

[windsurfr]

Try following an interventionalist around.... nice combo of rads plus you get the 'patient contact' and hands on experience. I would guess the future of IR is 'less uncertain' than that of rads because as of yet they haven't figured a way to cath a femoral via telemedicine from india....

 

[Airborne]

I wouldn't worry to much about outsourcing either.

It could be argued that the surgeons may soon be worried too - is it not unfeasible that a laparoscopic surgeon in India tell the scrub nurse to insert a specific instrument as they procede during the surgery? Indeed, such practices are beginning to be postulated for remote areas in the US so that qualified surgeoins can perform emergent surgery in these isolated areas. Thus why can't a qualified surgeon from other countries perform these operations as a fraction of the cost?

For that matter - why not internet based general practice where the history is entered into an algorithym - and a diffential diagnosis printed out? (which is nearly 80% of the input that leads to the diagnosis anyway)

I suppose it really boils down to "laying upon the hands" - While I can appreciate that Night Hawk services do not provide this, they do provide comfort in knowning that a BC radiologist has read the film.

Can the foreign Doc do the same? I am sure they can. Even if they are not US BCed. Indeed, I would feel just as safe in the UK suffering from an acute abdomen... Maybe even more so.


However, we, as Americans, have an innate distrust of anything beyond our borders. While US trained, BCed radiologists are more readily accepted to the general population - I doubt that anything less than this would be so.

If in doubt - ask your mother who she would rather have interpret her Head CT for a presumed stroke? 1) a tired US BCed radiologist in the middle of the night awaken from his/her sleep? 2) a US BCed radiologist awake and alert on a 1-2 year sabbatical in Australia or 3) a foreigned trained radiologist, whether alert or not - competent or not - and without any sort of US based qualifications (I do not mean this to be an attack on foreign trained Docs, as I have had fantastic relationships with them, but merely state the prevailing US public opinion).

In light of our ethnocentric culture, I am sure what her opinion would be.

Regardless, I do not think that outsourcing will be an issue in our practices to come.

Airborne

 

[ApacheIndian]

Good post Airborne.

 

[droliver]

Originally posted by Airborne
I wouldn't worry to much about outsourcing either.

It could be argued that the surgeons may soon be worried too - is it not unfeasible that a laparoscopic surgeon in India tell the scrub nurse to insert a specific instrument as they procede during the surgery? Indeed, such practices are beginning to be postulated for remote areas in the US so that qualified surgeoins can perform emergent surgery in these isolated areas. Thus why can't a qualified surgeon from other countries perform these operations as a fraction of the cost?

Airborne,

while I have enjoyed your thoughts on this subject, this comparison with tele-surgery is not very valid. You're comparing procedural versus diagnostic modalities. Those surgeries require someone on site,in the OR who can do the procedure as well as the distant "operator". These demonstrations have been mostly pony shows for the media of what are usually simple procedures to demonstrate that something can technologically be done remotely. There is little interest in this technology @ large and certainly there will be no cost-savings or outcome-based improvements ever achieved by this process (in distinct contrast to tele-radiology in re to cost). The more valuable part of the technology is likely to be the instant feedback available from someone watching distantly rather then technical assistance. It is hard to imagine that this would be of use in underserved/isolated for emergent procedures versus the stabilazation & transport ASAP as is the model now.

As to the case for foreighn surgeons being cheaper..... if you saw how little the surgeon costs are out of total hospital costs you'd be shocked. Unfortunately, the "phone bill" for maintaining the networks supporting the telerads part would likely exceed the surgeons fee stateside

In contrast, I think you're a little too dismissive of the prospects for telerad outsourcing catching on. Interpreting images distally has a pretty established track record already. It makes so much sense to me that this is coming widespread as stateside hospitals, health networks, and radiologists (like everyone else) look to contain their costs. Liability issues are the only thing I think stand in the way for now. However, if your insurer or the employer paying for your insurance can tell you what medicines you can get as part of your health plan (as they do now with formulary restrictions,specialst referrals ,& the like) is it really such a stretch for them to use this kind of system as cost-saving device for large scale health care systems over thousands over imaging studies.

BTW, I'm not advocating this position. I think personal interaction with my counterparts adds a great deal with putting image readings into some context & getting more accurate & useful reads.

 

[eddieberetta]

droliver,

The major issue is with credentialling, not tele-medecine. You are right that surgery (at least for now) needs on-site operators. However, that operator does not need to be board certified or well-trained. Who said that the non-BC'd surgeon getting paid pennies on the dollar had to be in some other country! Yes, radiology can be done remotely, but that is not the issue. The issue is whether people doing medical acts here should be certified here. The price of any procedure, be it surgery, imaging, anesthesia, will drop if people with less training are allowed to do it.

The quality will also drop.

And your comment about on-site colleagues is very apt. In addition to the clinical belefit, there are many tasks a radiologist does that require them to be on-site. In adddition to procedures, there is protocoling of scans, quality improvement, supervision of imaging (such as ultrasound but even other modalities) and a lot of day-to-day stuff involved in running the dept.

 

[droliver]

I think the credentialing issue is going to be pushed aside. IF you can get reliable & cheaper image interpretation by this technology, other physicians,payers, hospitals,& patients are going to embrace it. Image interpretation (be it radiographs or path slides) are somewhat unique in that they often can be validly reviewed anywhere,anytime. I think (right or wrong mind you)most physicians don't consider film or slide reviews a "medical act" that will engender some special protection for stateside radiologists. If clinicians are comfortable with the quality of the work, they do not care who is reading it. If they're not (and I assume liability will make many reluctant to do it) they will continue to insist on BC/BE radiologist review

As for quality of interpretation..... you may feel that this will drop, but this is something that will have to be studied to support that. Clearly programs (some very prominent ones included) already adopting this are already comfortable with quality control.


Back to the tel-surgery issue. The on site operator in fact DOES have to be able to do whatever the procedure is or be skilled enough to do damage control in the event of that. In addition, there is a de-facto requirements for board-eligibility in Surgery & credentialing by the hospital to perform these procedural events and you wouldn't be able to do these without a BE/BC surgeon in the room (this is again is one of the factors why the cost savings of tele-rads cannot be achieved for this)

 

[eddieberetta]

Well, droliver,

If one agrees that radiology is a medical act which should be performed by physicians, then it is evident that allowing unlicensed imaging reads is akin to allowing other unlicensed providers to act in their sphere (like technicians, non-licensed MDs operating) -- indeed, this is starting to happen. Quality is a major issue, but it is not as easy to measure as you might think. If a tech could be trained to do CABGs better than a CV surgeon, should we credential them as independent surgeons (say OR only, no clilnics)? And how do we know that all techs are as good as that one tech? This is why we have BCertification!

The defacto standard of having BCertification applies to radiology hospital credentialing also! The current outsourcing schemes are all either done by BC'd radiologists, or supervised by them. It is this latter point that concerns most of us (we worry that the supervision is inadequate). NB Cost savings would most certainly be realized if less-trained, non-bc'd technicians were allowed to perform surgery (or other medical acts)!

I think most MDs recognize radiology as a branch of medicine. Do most MDs think imaging is some "black box" procedure, like the measurement of a Hct or CBC? Often, the diagnosis hinges on a clinical history, demographic information, or a profound knowledge of pathology -- stuff you learn in medical school. The differentials in radiology are as intense as in internal medicine, the anatomy is as intense as in surgery. Radiology is subtle and needs to be done by well trained physicians. I don't think that's going to chage.

 

[droliver]

Eddie,

you're mixing procedures with non-procedures with your points in your last post. The arguments, pro & con for those things are a little different with the appropriate use of non-physician providers. There is a well-established role for non-surgeons assisting & performing some surgical procedures already. Nurses already deliver anesthesia with minimal MD oversite. Junior radiology residents with incomplete & minimal training interpret important films @ most trauma centers alone @ night all the time everywhere. In fact, the senior & presumably better radiology residents do the LEAST night work in most programs hierarchy.

An xray is an xray is an xray (or CT,ultrasound,HIDA,etc)... and it is not a clinical or procedural modality, its a diagnostic one. It's also a static one,unlike procedural events which require some onsite skill & judgement.These characteristics, combined with modern communications lend Diagnostic Radiology itself to outsourcing (period)- be it across the state or across the world. I think that's the take home message. Again, if your survey clinicians they don't care who interprets the image (a BC radiologist, orthopedist,neurologist, surgeon, radiology resident,or someone in New Delhi) as long as they get reliable reads. For example: radiology residents- I've had to do clinical treatments based on their readings of films at night before. Some are a lot better then others & I trust their reads, while some others I wouldn't bother wasting my time to get consultation. The fact that a non-BE radiologist (the resident) read a film without staff for me was much less important then the fact that they read it right


If these service deliver quality work they'll succeed I think in some markets. If the liability is too hot, it'll fail.

 

[eddieberetta]

Well the whole purpose of board certification is to ensure that at some point, people calling themselves (e.g.) radiologists meet a certain standard, so that you do not need to check each individual by running an RCT to see if they know anything. Obviously people want medical services (like surgery, imaging, IM) to be done ACCURATELY and CORRECTLY. It isn't that ONLY BC'd doctors are any good, it is that all of them have met that level. Your aregument is like saying that patients want a surgeon who is competent and good-- they don't care if he is an "MD' with "BC". This is true, but the MD with BC guarantees a certain minimum quality product!

Evidently, you feel that this kind of standardization is necessary for "procedure" specialties but not for "diagnostic" specialties. I disagree. Unfortunately, what you and I think is moot. For both types of specialties (and let's be honest, many such as IR, Cards, Resp -- hell even DR has procedures -- are in-between), non-certified providers are making huge inroads. It won't matter whether they are based in the US or abroad: they will exert a negetive pressure on jobs.

Just because the mid-level providers are "assisting" now does not mean that they will stay like that forever! Next thing you know, they will be training surgical interns.