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undecided3279

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I was in your shoes and was very conflicted between IM (planned a fellowship in cardiology or GI) or radiology. I applied to both IM and radiology programs, but withdrew my applications to IM. I am happy I chose radiology.

Radiology is a great gig for the right personality. You have to enjoy studying and there is lots of it in residency. It is medical school 2.0. You also have to enjoy finding a diagnosis on imaging. Try a test run with X-rays of the chest. If you enjoy it, then radiology may be for you. The first year of radiology is very overwhelming and can be tiring. Yes, my first year of radiology and probably even second year, were more tiring than IM prelim/internship year. But I still enjoyed it. You get to really learn medicine and pathology. And you cannot know it all (it is impossible), and that is fun.

Internal medicine is a great and VERY important field, but internists spend most of their time on a computer writing notes and dealing with patients. Patient interaction is very overrated these days, and I actually enjoy patient interaction. Now it is about moving the meat and seeing the next patient, unless you do concierge medicine. I would rather spend that computer time actually doing medicine intellectually. Several of my IM attendings in internship were surprised I was going into radiology and thought I wasting my talent. My spouse is an IM subspecialist and I do not envy when she has to prep for clinic, review charts, write and sign notes, call patients with results of their labs and pathology from their procedure, and deal with the catastrophic disaster called EPIC inbox (good in idea but very onerous on patient-facing physicians).

Now to the downsides of radiology. Volumes! They are high! There is a lot of pressure to read fast and be reasonably accurate. Our practice fired a radiologist who was very very slow (could not get through 15 CTs in a 9 hr day). I believe she went to the VA (generally lower volumes but also lower pay). There is a case of a radiologist in another health system who is suing her employer for wrongful termination saying she was pressured to read at a pace that was not safe. Our referrers have no idea what we deal with and some think we are overpaid. We use our forebrains and concentrate for more hours in the day than any physician. Imagine driving for 8 hrs -12 hrs and the concentration that requires. A lot more is required for radiology or you miss stuff. The days can be tiring sometimes but the pay is good, although you work hard for it. I work 50-60 hrs a week, but I chose to work a bit more.

As far as misses, know that EVERY SINGLE radiologist has missed something important in their career. I have, and my colleagues consider me to be excellent. I read 1500-2000+ studies in a month of which AT LEAST 700+ are cross-sectional (CT, MRI, PET/CT). Suppose my miss rate is <0.1% or >99.9% accuracy. That means I could miss 10-20 important findings in a year (I hope that is not the case). However, the key is not to miss something obvious. One of my attendings in residency "missed" a very subtle breast mass that would be nearly impossible to call prospectively. The mass got bigger on a later study and required a mastectomy. The patient sued after her mastectomy but she lost as it was decided that making that call was not reasonable. Making that call means a higher call-back rate and many women getting unnecessary diagnostic mammograms/breast ultrasounds.

The other issue is lack of histories on imaging requests. For some reason referrers think we are magicians and mind-readers. Lack of good history certainly contributes to misses and lower-quality reports, but it is what it is. As I say, garbage in, garbage out. In those cases, I put in the likely differentials and tell them to correlate clinically. :)

Surgeons and subspecialists like to bloviate about being able to read imaging better than us. An ENT surgeon should be good at looking at temporal bone CT and will probably do a better job than a radiologist who is not fellowship-trained in neuroradiology, but the ENT will miss the stroke or the brain bleed or mass. Neurologists can read vascular imaging for strokes, but will likely miss the dural sinus thrombosis, mediastinal mass, pulmonary embolus, fracture or ENT neoplasm. I have seen examples. I read a classic case of upper extremity weakness which was due to an obvious displaced humeral fracture that no one saw because of tunnel vision focused on a stroke. I also read body imaging, and I will thoroughly outread any general/abdominal surgeon when it comes to abdominal CT and MR. Give us a stack of 30 abdominal CTs with 3-4 hrs to read them all and with little to no history and see who does a better job. It won't be close. I guarantee it.

Finally, radiology is a thankless jobs. You get more complaints than gratitude, despite radiologists being VERY important in medicine, regardless of what anyone has told you. Back in training, there was an IT problem which prevented the docs from seeing the resident reports on call. Our phones were blowing up for over a 1 hour with docs (including surgeons) asking for prelim verbal reads.

No regrets with picking radiology. It works well for me and suits me perfectly.
 
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While I considered IM because there is a lot of cool stuff to learn, the day to day just sucked to me. We spent all day thinking about everything that everything could be only to then write a note that says “condition is multi factorial. Appreciate specialist recs. Avoid nephrotoxic medications.” Then you spend your day putting in diet orders and being harassed by social workers.

I also gravitated toward the more intellectual non-procedural fields and felt that training just as long as rads to make less than a hospitalist was stupid.

The only downside to rads is that the vast majority of your colleagues have little respect for what you do and the volume. All of our fellowships are non competitive so no grinding research and *** kissing in residency to hope you get to do what you want.

It’s not all about money but our pay overlaps considerably with interventional cards and eclipses the other ones. But we typically have more vacation than them (often twice as much). There are opportunities to join groups that just don’t work nights, too since you mentioned lifestyle concerns.
 
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If you are in between, I think radiology would be a better choice IMO. Better lifestyle and more $$$.

I am not sure general radiology has more autonomy / leverage in the hospital than IM. I think it might be the same because both are not generating a lot revenue.

I like my job as a hospitalist mostly because of flexibility; the money is not bad either. If I were younger when I was in med school, I would have chosen radiology. I was also in between IM and radiology.
 
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The only downside to rads is that the vast majority of your colleagues have little respect for what you do and the volume.

They may not understand the volume, but I believe internally they respect what we do even though they may not say it out loud. I believe that jealousy, combined with the idea that we don't see patients, somehow contributes to the perceived disrespect. Caveat is that, the disrespect is not everywhere, I trained at a very strong program, and our department was highly respected in the hospital. Fellowship at a different institution (also a top radiology department) was different. It was odd and very laughable to see senior IM residents try to lecture me over the phone on lung CT. Oddly though, at this same institution, there was a tumor board that no attending or radiology fellow could attend. I thought the surgeons and oncologists would proceed without us. Guess what? It was cancelled.

Once cardiologists get a taste of imaging, they try to do more of it (not less) and decrease patient-facing encounters. At one institution, they were reading myocardial perfusion PET/CT without any radiology over-reads. In their reports, they would say that the CT was for attenuation correction and not interpretable for extra-cardiac structures. After a few successful lawsuits, they were happy to have radiologists over-read the studies and split the RVUs for the cardiac PET/CTs.
 
If you are in between, I think radiology would be a better choice IMO. Better lifestyle and more $$$.

I am not sure general radiology has more autonomy / leverage in the hospital than IM. I think it might be the same because both are not generating a lot revenue.

I like my job as a hospitalist mostly because of flexibility; the money is not bad either. If I were younger when I was in med school, I would have chosen radiology. I was also in between IM and radiology.

The radiology department is one of the (if not the highest) revenue generator for hospitals. The technical fees for imaging procedures are quite good. What sucks is the professional/physician reimbursement. A chest X-ray reimburses <$10.
 
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They may not understand the volume, but I believe internally they respect what we do even though they may not say it out loud. I believe that jealousy, combined with the idea that we don't see patients, somehow contributes to the perceived disrespect. Caveat is that, the disrespect is not everywhere, I trained at a very strong program, and our department was highly respected in the hospital. Fellowship at a different institution (also a top radiology department) was different. It was odd and very laughable to see senior IM residents try to lecture me over the phone on lung CT. Oddly though, at this same institution, there was a tumor board that no attending or radiology fellow could attend. I thought the surgeons and oncologists would proceed without us. Guess what? It was cancelled.

Once cardiologists get a taste of imaging, they try to do more of it (not less) and decrease patient-facing encounters. At one institution, they were reading myocardial perfusion PET/CT without any radiology over-reads. In their reports, they would say that the CT was for attenuation correction and not interpretable for extra-cardiac structures. After a few successful lawsuits, they were happy to have radiologists over-read the studies and split the RVUs for the cardiac PET/CTs.
I really have not sensed the disrespect that OP talked about, then again I have been a doc for only 6 yrs (residency included).
 
One of my attendings in residency "missed" a very subtle breast mass that would be nearly impossible to call prospectively. The mass got bigger on a later study and required a mastectomy. The patient sued after her mastectomy but she lost as it was decided that making that call was not reasonable. Making that call means a higher call-back rate and many women getting unnecessary diagnostic mammograms/breast ultrasounds.
Can I ask what state this was in? I think there are many physician unfriendly states where the patient would have won that lawsuit and radiologists often have to settle for a LOT. Especially since the jury of laypeople have no idea what is considered reasonable and prosecution brings a in a biased "expert", add in the emotional and societal prominence that cancer, especially breast has in most peoples minds.
 
Can I ask what state this was in? I think there are many physician unfriendly states where the patient would have won that lawsuit and radiologists often have to settle for a LOT. Especially since the jury of laypeople have no idea what is considered reasonable and prosecution brings a in a biased "expert", add in the emotional and societal prominence that cancer, especially breast has in most peoples minds.

I cannot say for anonymity reasons, but it is a physician friendly state. I agree that the wrong jury could have voted differently.
 
I cannot say for anonymity reasons, but it is a physician friendly state. I agree that the wrong jury could have voted differently.
Yeah unfortunately I think that's a big point against the field..
 
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