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Genuinely curious - what are the big factors that contribute to Radiology burnout?
Is it mostly because of high volume or are there other factors I don't understand as a non-radiologist?
Thanks in advance.
 
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Genuinely curious - what are the big factors that contribute to Radiology burnout?
Is it mostly because of high volume or are there other factors I don't understand as a non-radiologist?
Thanks in advance.

1. Ever escalating volumes and responsibility despite stagnant pay (though in the grand scheme of things it is still good pay). By responsibility I mean the fact that the ability for diagnoses to be made or excluded primarily on imaging (and a bit of history) has grown exponentially because of improved technology, availability of technology, and/or an improved understanding of how to interpret imaging by radiologists.

E.g. Whereas before an ED physician may have had to make a decision for tPA for edge cases based off of a strong history/physical and a negative noncontrast CT, nowadays these patients typically get either CTA or MRA. For this to work radiologists are working later hours and take on greater responsibility in the diagnosis and downstream management.

2. Referring/ordering physicians who don't do due diligence. Because of the above reason, some physicians are opting to go more or less straight to the scanner (i.e. "Airway, Breathing, CT" ABCs of ER) rather than do a thorough history and physical, which may have avoided the use of unnecessary imaging. The fact that some of these physicians go on to become academics means that the next generation of physicians don't develop the same level of clinical skills as some of their predecessors who didn't have advanced imaging readily available, which further worsens the issue.

3. Improved technology in radiology has led to MORE work most of the time. We have doubled our resolution on many scans and now have multiplanar reformats and high resolution reconstructions become the norm, which on average is at least 2-3x more work now compared to 'the old days' of the 16 slice non-contrast head. This hasn't happened for most other specialties.

4. The relationship between radiology and referring physicians (some of them) can at times be like the relationship between a PCP and patient, i.e. overly demanding and not understanding what you actually do. This is overly simplified since it goes both ways! But my experience is that rarely do radiologists truly obstruct imaging, whereas unnecessary/over-imaging is the norm. Hence why we are continuing to see rapid increases in use of imaging.

5. Increasing penetration of corporate types into radiology. Unfortunately this is pretty much affecting all of medicine.
 
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guytakingboards

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Genuinely curious - what are the big factors that contribute to Radiology burnout?
Is it mostly because of high volume or are there other factors I don't understand as a non-radiologist?
Thanks in advance.

There's kind of a fine line between what's merely unsatisfying about radiology and what is truly causing burnout. The poster above mentioned a lot of good points, but i think they all hit the point of "higher volume is bad", which is true in any field.

What I think non-radiologists don't understand about radiology is intensity-level that we perform at consistently (on-call). It's not uncommon to have a call shift where, other than getting up to pee and maybe answering phones calls, we're reading a huge stack of acute cases. 80-100 acute cross sectional cases where the radiologist's input directly drives patient care. Baseline that's like a 7-8 out of 10 on the stress scale.

I remember clinical medicine calls; in my opinion, people wildly underestimate just how much time they spend doing low-intensity activities: calling consults, walking to see a patient, putting in orders, writing notes, waiting for a trauma patient to arrive, doing the closure on a surgery, etc.... I would liken radiology to doing the most intensive part of a surgery, some sort of delicate anastamosis, for 8-10 straight hours. Or running 8 codes in 8 hours. That's gonna be mentally fatiguing.

Another thing that contributes to burnout is the often depersonalizing nature of radiology. You can feel like a cog in the machine just cranking out reports. We're just "radiology" and what we do is just a few extra clicks in the order entry system. Sometimes if feels like we're held on the same level of importance as the nursing order to wipe the patient's ass. There's not often a lot of positive feedback in the job and a high-level of performance is the expectation not the hope. God help you if you miss something because you will be thrown under the bus.

If I extended this to things that are just really unsatisfying about radiology, this post would be way longer.
 
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Interpersonal feedback to establish a sense of professional efficacy is required to prevent burnout.
 

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Interpersonal feedback to establish a sense of professional efficacy is required to prevent burnout.
I learned in business school that even minor acknowledge of other people's work greatly affects their morale and reduces burnout. I have found that to be true in my previous blue collar work and professionally as well. It is a small but real risk of radiology to not receive this type of acknowledgement, in my opinion. I think it illustrates the general importance of having a "good" job.
 
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Do you guys think the increasing volume is leading to positive change ie increased demand for radiologists or a negative ie the workload continues to go up while the pay remains stagnant or gets cut?
 
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This is really helpful, thanks for responding. I’m going to bring up a few things but happy to listen to critique about them, and I acknowledge this is just how I feel. I’m starting a discussion to figure out what I don’t know about other specialties like radiology:

1) In terms of more studies being ordered, I wouldn’t call it ordered by just physicians; there’s a much larger number ordered by “providers” including NPs etc. Also a large number are ordered nowadays because of patient demand rather than physician recommendation. With “patient satisfaction” being such an important thing, most patients demand more and more docs end up giving in (especially as burnout goes up, ironically)

2) I’d argue improved technology in the sense of the internet and patient portal is definitely more work for other specialties. Don’t discount that technology is better in many ways so this IS affecting all doctors, albeit perhaps in different ways than radiologists. Trust me you’d rather see more cuts than answer 27 more patient portal messages about the chest pain they had for 2 seconds but then went away and now they want an explanation and/or they want more information about how to get tested for something they read about online or they read a special website that said your assessment was inaccurate, or just any other message that enters their head at 2am, etc.

3)The consistency of radiology does sound tough but again, I wouldn’t discount how much more “spare time” other specialties have. This is definitely a “grass is greener” issue but you’re definitely entitled to your experience. It also sounds like this is more of an issue when you’re on call/doing ER work (which in fairness, pays better).

4) this is a good point you bring up about getting feedback/acknowledgement. I could be better about doing this and have never thought about it. Going to start doing this.

5) also interested in this question about whether increased use of imaging should lead to more demand of radiologists too, right?

Thanks for your responses.
 
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guytakingboards

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This is really helpful, thanks for responding. I’m going to bring up a few things but happy to listen to critique about them, and I acknowledge this is just how I feel. I’m starting a discussion to figure out what I don’t know about other specialties like radiology:

1) In terms of more studies being ordered, I wouldn’t call it ordered by just physicians; there’s a much larger number ordered by “providers” including NPs etc. Also a large number are ordered nowadays because of patient demand rather than physician recommendation. With “patient satisfaction” being such an important thing, most patients demand more and more docs end up giving in (especially as burnout goes up, ironically)

2) I’d argue improved technology in the sense of the internet and patient portal is definitely more work for other specialties. Don’t discount that technology is better in many ways so this IS affecting all doctors, albeit perhaps in different ways than radiologists. Trust me you’d rather see more cuts than answer 27 more patient portal messages about the chest pain they had for 2 seconds but then went away and now they want an explanation and/or they want more information about how to get tested for something they read about online or they read a special website that said your assessment was inaccurate, or just any other message that enters their head at 2am, etc.

3)The consistency of radiology does sound tough but again, I wouldn’t discount how much more “spare time” other specialties have. This is definitely a “grass is greener” issue but you’re definitely entitled to your experience. It also sounds like this is more of an issue when you’re on call/doing ER work (which in fairness, pays better).

4) this is a good point you bring up about getting feedback/acknowledgement. I could be better about doing this and have never thought about it. Going to start doing this.

5) also interested in this question about whether increased use of imaging should lead to more demand of radiologists too, right?

Thanks for your responses.

No prob. Always happy to having a running dialogue with the clinical teams to better explain what we do and how we can help them.

I didn't intend to imply that other specialties have more spare time. Those low-acuity tasks I described are necessary and integral to the way your job is performed. It's not wasted time. Part of why people are drawn to radiology is that we spend a higher proportion of our working time doing high-stakes tasks. Unfortunately, that can definitely go too far. Radiology's not too dissimilar to ER and critical care at times, other fields prone to burnout.

Most of the volume complaints are related to call-work. Yes, the volume expectations for regular day work are getting higher but in general if you're burning out from day-work you picked the wrong job.

There was one particular instance a few months ago that just had me shaking my head about the acknowledgement of radiology in clinical medicine. A patient with weird neurologic symptoms was admitted from the ER to an IM service. The IM service orders the standard non-con head CT. Fine. They also consult neurology. Neurology recommends a brain MRI and an LP as well as an ID consult. I read the brain MRI; it's a super weird MRI. ID sees the patient and seconds the LP. The patient comes down to radiology and we do the LP. It's an acutely ill-hospital patient, so it takes probably 45min to get pressures and a decent enough sample of CSF.

I'd say all-in-all, I spent close to 1:30 on that patient's care that day between reading the weird brain MRI, scouring the internet for possible differentials, reading through the labs/chart, consulting fellow radiology colleagues for second opinions as well as doing the LP. That had to be as much if not more time than those other consulting services. I have as much if not more training than the neurologist and ID docs and certainly more than the IM doctor. Yet in the daily progress IM notes, it said "neurology consulted, appreciate rec's from Dr. XYZ. ID consulted, appreciate rec's from Dr. XYZ". My entire brain MRI impression was copied into their note, zero acknowledgement. "LP performed yesterday" was about as much acknowledgement as I got. It was just emblematic of how clinicians view radiologists these days.
 
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I can definitely understand the frustration in that and that's impressive you did what you did. For what it's worth, there is A LOT of stuff that most docs don't get acknowledged for but I can imagine it feels even more differently for you guys. I think one of the biggest issues in medicine is that we think other specialties have it "better" or aren't carrying their weight in the medical care of a patient. I think everyone feels like they're working harder/more than their other colleague specialists. We need to find a way to have physicians not be against other physicians.
That being said, your frustrations are valid so thanks for sharing.
 

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3)The consistency of radiology does sound tough but again, I wouldn’t discount how much more “spare time” other specialties have. This is definitely a “grass is greener” issue but you’re definitely entitled to your experience. It also sounds like this is more of an issue when you’re on call/doing ER work (which in fairness, pays better).

I am at a high-end academic medical center, and our IR residents and fellows compare their IR call to their general radiology call. IR call is busy without too much time downtime since there are few fellows covering a large health system; despite this, they almost always consider IR call a bit of a break when compared to general diagnostic radiology call. Some of the IR residents/fellows partake in ICU/SICU rotations, and DR work to them is relatively more intense, especially on a per unit of time metric.

My co-residents all felt more mentally tired working 50-60 hours a week in radiology compared to internal medicine or surgery intern year where many of us routinely worked 70-80+ hours/week. The closest analogy is focused non-stop driving for 10-12 hours, but this not an apt comparison since diagnostic radiology requires even more mental focus/intensity, or else miss rates go up.

Medicine is not easy and every specialty is important for good patient care, however radiology is probably the most misunderstood specialty. When I tell people I am in radiology, many times I get responses suggesting that the work/workload is easy. This assumption, in part, leads to unrealistic expectations from our more clinical colleagues.
 
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I have heard attendings saying that they feel pressured to read more and more studies these days and to clear the list. They also saying that in some PP you have a RVU meter on your desktop to monitor your productivity, like wow. With the new CMS cuts to radiology (-11%), I can only imagine all of this getting much much worse.
 
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I can definitely understand the frustration in that and that's impressive you did what you did. For what it's worth, there is A LOT of stuff that most docs don't get acknowledged for but I can imagine it feels even more differently for you guys. I think one of the biggest issues in medicine is that we think other specialties have it "better" or aren't carrying their weight in the medical care of a patient. I think everyone feels like they're working harder/more than their other colleague specialists. We need to find a way to have physicians not be against other physicians.
That being said, your frustrations are valid so thanks for sharing.

Those are a couple of different ideas in my opinion.

1) Personally don't agree that a big issue in medicine is low-key jealously that other specialties have it better or aren't carrying their weight. Maybe that's just the field I'm in but I couldn't care less if Ortho trauma works more or private practice derm works less. The caveat is that i do feel other specialties aren't carrying their weight when radiology gets BS little procedures after hours that medical doctors or surgical specialists don't want to do. E.g. the percutaneous nephrostomy that nephrology or urology would happily do M-F from 8-4:30 but if its 5:30 --> call IR.

Was covering a weekend shift at the local county/teaching hospital a few months ago, when I got a stat request from the neurology service for an LP. I look up the patient. It was a 24 y/o young lady who was hospitalized for possible new diagnosis multiple sclerosis. Looked at her imaging. Maybe 110lb soaking wet with perfectly normal anatomy. I call the neurology service (/resident) and say "1) why is this stat? 2) there couldn't be a more perfect patient for you to do an LP on as a trainee", why aren't you doing this? 3) is this seriously stat?". He replies "yadda yadda yadda we're actually not signed off to be able to do these independently". I said whatever, brought the patient down, stepped on fluoro once to see where L2-L3 was and dropped the needle. Almost certainly could have done it without fluoro. In retrospect I should have told that resident, "if you are not qualified to do this procedure, you better call your faculty in". I still had to read 70-80 acute cross sectional that shift. /rant

2) "I think everyone feels like they're working harder/more than their other colleague specialists. " --- maybe? Maybe it's just ego, but I truly believe call-radiology might be one of the pound-for-pound most mentally fatiguing endeavors in medicine. Not the same thing as tiring. I've been a surgical intern doing 80-100hr weeks on pediatric surgery and liver transplant. I know tired. Mental fatigue plus exhaustion is way worse.

This may or may not be an broadly applicable analogy but I liken it to having studied for Step 1 for 3-4mo and reaching that brain-fried burnout period. Radiology can be like that. I remember first year of radiology residency, i had that burnout headache for 2-3 hours after work every freaking day for 6 months. Same thing happened when I became a fellow (for a much shorter period) and an attending (probably 2-3mo of burnout headaches after work).

I read something a while ago that neatly explained why new students/trainees don't actually understand what radiology is like. When medical education was formally organized over 100 years ago, the requisite experiences were the only specialties available at the time: Internal Medicine, Surgery, Ob-GYN, family medicine and psychiatry. Those continue to be the only core clerkships in most schools' curriculum. Things like radiology, rad-onc, and surgical subspecialties (things that play a crucial role in modern medicine) people get only a limited exposure.

I rotated through all those core specialties; it may be ignorance but I do feel like I have a grasp of the daily plight of internal medicine/surgery/family medicine. Maybe not exactly how terrible it can be, but big picture. Can't say I've encountered a non-radiologist who really understood the in's and out's of radiology.

3) "We need to find a way to have physicians not be against other physicians." A running dialogue is the start. Thanks for jumping in.
 
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A big component for me is that being in radiology you have no control over all the studies being ordered, as someone alluded to earlier.

Especially being on call, ER docs will order excessive exams to CYA, and most often than not, the radiologist just has to suck it up and read them.
 
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The RVU pressure is real and it’s everywhere. That is truly in every part of medicine and trust me, it does affect everyone who has to deal with it.

Thanks for sharing your experiences in Radiology. It does sound like there is a good reason for the high level of burnout. I still do have to say I don’t think radiologists understand non-radiologist jobs very well and as you alluded to, vice versa. We all need to be careful when assuming our jobs are “worse” though maybe they aren’t “better.” I also think rotating through as an intern is VASTLY different than what things are like as an attending so that comparison isn’t exactly accurate but again, I can acknowledge radiology has burnout for a good reason. Also dealing with patients directly is a whole another ball game that I can’t even begin to get into. I know radiology does a little bit of that but providing perfect customer service and dealing with all the personalities and entitlements and demands all day is just another beast.

Out of curiosity, do you think most radiology jobs are like this? Does it matter if you are academics vs private practice? If you don’t pick up extra calls/shifts? Or you think this is relatively common across the board?
 
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guytakingboards

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The RVU pressure is real and it’s everywhere. That is truly in every part of medicine and trust me, it does affect everyone who has to deal with it.

Thanks for sharing your experiences in Radiology. It does sound like there is a good reason for the high level of burnout. I still do have to say I don’t think radiologists understand non-radiologist jobs very well and as you alluded to, vice versa. We all need to be careful when assuming our jobs are “worse” though maybe they aren’t “better.” I also think rotating through as an intern is VASTLY different than what things are like as an attending so that comparison isn’t exactly accurate but again, I can acknowledge radiology has burnout for a good reason. Also dealing with patients directly is a whole another ball game that I can’t even begin to get into. I know radiology does a little bit of that but providing perfect customer service and dealing with all the personalities and entitlements and demands all day is just another beast.

Out of curiosity, do you think most radiology jobs are like this? Does it matter if you are academics vs private practice? If you don’t pick up extra calls/shifts? Or you think this is relatively common across the board?

Fair points. I don't actually know what it's like to be an attending in any other field.

Haha yes, Dealing with patients is entirely different ball game, one I happily ran away from. However..... our customers are the clinicians and boy do they come with their own personalities, entitlements and demands all day.

Scenario: IR with a completely full schedule of elective outpatient and emergent hospital procedures: "I WANT THIS PICC DONE NOW SO I CAN DISCHARGE HIM TO A SNF BEFORE THE WEEKEND"
Scenario: Tumor board. Neurosurgeon "I can read brain MRIs better than the radiologist. Why do we even need them".
Scenario: Brand new family medicine NP. Orders a lumbar spine MRI, lumbosacral plexus MRI, and a MSK pelvis MRI for back pain with a radiculopathy. Facepalm
Scenario: Peds GI: "Can you addend your abdominal radiograph report, I think it's really a severe stool burden but you said moderate"
Scenario: Pain doctor: "you didn't mention mild facet arthrosis on the right at C5-C6. did you not see it? I need you to addend your report so i can inject that facet"
Scenario: Pulmonologist: "you mentioned >10 pulmonary nodules in your chest CT report. I need you to go back and give image numbers, arrows and measurements in 3 planes".
Scenario: Patient read her own CT report and was referred from clinician directly to me to go over the results of a Neck CT for a "patient feels a bump on their neck" work-up which was negative. "Ma'am there's nothing at the spot you noted...... well there's normal structures like the jaw bone and the submandibular gland.... you want me to addend the report stating all those normal structures are possibilities for what you feel?!?" ---- real 45 minute conversation i had one day.

Believe me, customer service is alive and well in radiology.

Are most jobs like mine: yes and no. Call-shifts in most avenues of radiology are bad to pretty bad, regardless of academics vs PP. One of my co-fellows is in academics; he says its common to read 200 cross-sectional studies across Saturday and Sunday. He has trainees drafting reports, but he still has to go through 200 studies. I would say overall PP leans worse, because PP groups really like to cut staffing to barebones to enable more vacation time.

I don't pick-up extra call shifts commonly. They're pretty brutal.
 
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Haha, those are great examples!
I'm digressing to stuff out of our control now but part of the issues we're facing as physicians are that:
1) medicine has become all about the bottom line (note: doctors don't see that money people, but the hospital admin/CEO's/insurance people get more and more) and EVERYTHING has become about how to make more money; corporatizing hospitals and healthcare
2) because everything is becoming about making more money, patients are dictating their own care without any knowledge of their own health; they just care about people being "nice" and giving them what they want... which can lead to "better satisfaction scores" even if that ultimately causes more harm
3) we're told what to do by the people who know nearly nothing about healthcare: insurance companies, administration, patients
4) we are all practicing defensive medicine (hence why you get told to addend all the time and why there is such an upsurge of imaging being ordered)
5) Physicians keep comparing their specialties/work to other specialties while there are mid-levels literally taking over medicine with significantly less training and experience and this is really affecting quality of care. Not all, in fairness, but definitely a lot of providers practicing outside their scope and I think this is causing more issues for everyone; but we tend to focus on the surgeons vs radiologists vs internists etc
6) I can go on and on. Ok I'm ending my own rant now.
 
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Fair points. I don't actually know what it's like to be an attending in any other field.

Haha yes, Dealing with patients is entirely different ball game, one I happily ran away from. However..... our customers are the clinicians and boy do they come with their own personalities, entitlements and demands all day.

Scenario: IR with a completely full schedule of elective outpatient and emergent hospital procedures: "I WANT THIS PICC DONE NOW SO I CAN DISCHARGE HIM TO A SNF BEFORE THE WEEKEND"
Scenario: Tumor board. Neurosurgeon "I can read brain MRIs better than the radiologist. Why do we even need them".
Scenario: Brand new family medicine NP. Orders a lumbar spine MRI, lumbosacral plexus MRI, and a MSK pelvis MRI for back pain with a radiculopathy. Facepalm
Scenario: Peds GI: "Can you addend your abdominal radiograph report, I think it's really a severe stool burden but you said moderate"
Scenario: Pain doctor: "you didn't mention mild facet arthrosis on the right at C5-C6. did you not see it? I need you to addend your report so i can inject that facet"
Scenario: Pulmonologist: "you mentioned >10 pulmonary nodules in your chest CT report. I need you to go back and give image numbers, arrows and measurements in 3 planes".
Scenario: Patient read her own CT report and was referred from clinician directly to me to go over the results of a Neck CT for a "patient feels a bump on their neck" work-up which was negative. "Ma'am there's nothing at the spot you noted...... well there's normal structures like the jaw bone and the submandibular gland.... you want me to addend the report stating all those normal structures are possibilities for what you feel?!?" ---- real 45 minute conversation i had one day.

Believe me, customer service is alive and well in radiology.

Are most jobs like mine: yes and no. Call-shifts in most avenues of radiology are bad to pretty bad, regardless of academics vs PP. One of my co-fellows is in academics; he says its common to read 200 cross-sectional studies across Saturday and Sunday. He has trainees drafting reports, but he still has to go through 200 studies. I would say overall PP leans worse, because PP groups really like to cut staffing to barebones to enable more vacation time.

I don't pick-up extra call shifts commonly. They're pretty brutal.
Well this is demoralizing. The whole point of radiology is to have as little to do with other people and their crap as possible.
 
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I've kinda shot from the hip in this thread and went down the rabbit hole of things that suck about radiology. I do think it's a lot more difficult and misunderstood than non-radiologists know. That being said, there's plenty I like about my job. It's fairly intellectually stimulating. There's at least a few cases a day where I have to look something up and/or see something case report-level (whether already reported or not). There's a pretty wide spectrum of patient interaction, from zero in telerad to a significant amount in Mammo and IR. There still is a lot less BS side work than clinical medicine. Shift work can be a blessing and a curse; some days after i log out of my workstation at 4:30 i don't think about work until i log on the next day at 8am. Some days those shifts are so absolutely brutal I'm brain-dead and can't think about anything until the next day at 8am.

Insearchofwisdom, i read through a couple of your other posts. The only thing I can really say is make a move with your eyes wide open. Radiology does seem like the "grass is greener" to a lot of folks, but it's not all peaches and cream. I like my job; it's not perfect but most aren't. One of my chief residents ahead of me is now on his 4th job in less than 4 years.

Learning to make the best of the situation and/or minimizing your own burnout is key to whatever you end up doing. (as you can probably tell i struggle with it).

Well this is demoralizing. The whole point of radiology is to have as little to do with other people and their crap as possible.

Lol, all those examples I gave were over a long period. That's not a representative day.

One of the things I came to appreciate later in training and then in early attendinghood is that customer service is integral to the radiologic interpretation. Learn/know your audience and what they expect. ER doctors will always want "positive or negative". Oncologists want the details to upstage/downstage a tumor. Proceduralists want details that enable them to do procedures. Everyone wants the answer to a specific question in history "R/o appendicitis ---> No evidence of appendicitis or other acute abdominal pathology". Once you know your referrers that part becomes much easier. If you do the same boilerplate dictation for both a pediatric PA and a neuro-oncologist, someone is going to be confused or upset.
 
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theonlytycrane

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amazing thread to read through as an m4 preparing to apply DR this cycle.

Any tips on what would be the ideal academic or PP job that would minimize burnout?
 
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Another question that might be tangentially related -

Why do the reported income numbers vary so much for private practice groups by region? Like, why does a private practice rads in the midwest make +200k compared to a coast?

Are they working longer hours or reading more frantically to generate higher RVUs than their coastal counterparts? I don't mind the midwest and those salaries look attractive but they lose their appeal if it's just because everyone is burning the candle at both ends
 
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Well this is demoralizing. The whole point of radiology is to have as little to do with other people and their crap as possible.

More work is unavoidable in radiology. The impact of radiologists & imaging has risen meteorically (and will continue to rise), while the ability to take a H&P and make a diagnosis has stagnated and in some specialties perhaps even deskilled.

Still probably one of the best careers to have in medicine.

The annoying parts of radiology (which are subjective...) are like 95% of what you would spend time on in primary care specialties. I still remember the days on medicine making a million phone calls a day to specialists asking for help, asking for updates, asking for procedures, asking for reads/scans, then spending all the other time documenting what was already obviously in the EMR plainly with a few useful lines at the end of the note. No thanks.
 
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guytakingboards

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Another question that might be tangentially related -

Why do the reported income numbers vary so much for private practice groups by region? Like, why does a private practice rads in the midwest make +200k compared to a coast?

Are they working longer hours or reading more frantically to generate higher RVUs than their coastal counterparts? I don't mind the midwest and those salaries look attractive but they lose their appeal if it's just because everyone is burning the candle at both ends

Dunno exactly about PP model but employee salaries (e.g. in academics) in desirable locations are significantly lower than in flyover country. Heard stories of people interviewing for entry level faculty jobs in the Harvard programs being offered under $200k. Meanwhile I've heard associate prof's at CCF make in the 500's. Huge discrepancy.
 
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Gadofosveset

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Oct 3, 2014
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Also — a stealth cause of rapid burnout —

Surrounding yourself with negative people (or sometimes deranged people in the case of AM) will also very very quickly lead to burnout.
 
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