Why is radiology hot and pathology not?

[slim06]

Hey Folks,
With any luck, I'll be starting medical school this fall. From reading all the threads on this board, I notice that radiology is a very popular & competitive field. Yet pathology seems very unpopular. From my limited outside perspective, it seems like they're pretty similar fields, with similar work demands. Most of the day, you sit in a cushy chair and look at pictures and figure out what's going on in the patient. Obviously this comparison excludes therapeutic radiology where you zap patients with radiation. Any thoughts on why there's such a big divide?

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[emtji]

Hey Folks,
With any luck, I'll be starting medical school this fall. From reading all the threads on this board, I notice that radiology is a very popular & competitive field. Yet pathology seems very unpopular. From my limited outside perspective, it seems like they're pretty similar fields, with similar work demands. Most of the day, you sit in a cushy chair and look at pictures and figure out what's going on in the patient. Obviously this comparison excludes therapeutic radiology where you zap patients with radiation. Any thoughts on why there's such a big divide?

$$$

 

[cdql]

$$$

Radiologists are typically paid much better than pathologists. So if you're going to do "similar" work, most people opt for the higher paycheck.

 

[slim06]

Why more $$? Is it because they can bill for the fancy equipment while pathology is stuck with microscopes from the 19th century?

Maybe path should try to merge with rads. They could become the department of sitting in your chair and figuring out what's really going on.

 

[deuist]

While both professions "look at pictures" all day, their scopes of expertise are very different. Radiologists are very tech savvy and use a variety of techniques to look inside the body, usually at the same run-of-the mill complaints: broken bones, brain and spinal cord lesions, and occasionally pregnancy complications.

Pathologists do cancer screening, autopsies, and must possess a wide base of knowledge pertaining to the mechanisms of disease. With the exception of broken bones, most diagnoses come from pathologists, not the primary care physician or the surgeon. Path is a harder field intellectually, yet does not pay as much as other specialties. Also, while many of the pathologists I know are friendly, there is still a stigma that they are introverts who sit in a corner of the cafeteria and eat by themselves.

 

[deuist]

Maybe path should try to merge with rads.

We could call this new group the Department of Diagnostic Medicine.

 

[deleted87716]

We could call this new group the Department of Diagnostic Medicine.

I think that's taken. 😉

 

[TBforme]

While both professions "look at pictures" all day, their scopes of expertise are very different. Radiologists are very tech savvy and use a variety of techniques to look inside the body, usually at the same run-of-the mill complaints: broken bones, brain and spinal cord lesions, and occasionally pregnancy complications.

Pathologists do cancer screening, autopsies, and must possess a wide base of knowledge pertaining to the mechanisms of disease. With the exception of broken bones, most diagnoses come from pathologists, not the primary care physician or the surgeon. Path is a harder field intellectually, yet does not pay as much as other specialties. Also, while many of the pathologists I know are friendly, there is still a stigma that they are introverts who sit in a corner of the cafeteria and eat by themselves.

This is just plain wrong. Radiology plays a central role in the diagnosis of numerous diseases. In fact, it is least influential in some of the areas mentioned such as musculoskeletal (ortho reads their own films and rarely base treatment on the read by radiology). Many diagnoses have become dependent upon imaging: appendicitis used to be a clinical diagnosis but you will rarely see anyone get to the OR without a CT anymore. Abdominal pain in general almost always ends up gettiong a CT: diverticulitis, abscesses, renal masses/cysts, necrotizing pancreatitus, cholecystitis, colon CA. Pulmonary emboli are diagnosed by CT almost exclusively. Chest XRs and CT diagnose: pneumonia, effusions, nodules/masses. Everyone with a stroke gets a non-contrast head CT then eventually an MRI, carotid dopplers, maybe an MRA. Peds imaging: ultrasound for pyloric stenosis, upper GI for volvulus, air enema for intusseception, Meckel's scan for Meckel's.

Radiologists have a broad based knowledge of disease and its mechanisms. They can generate an annoyingly long differential for anything they see just like path.

 

[UCLAstudent]

I think that's taken. 😉

😍

 

[hardy]

I think that's taken. 😉

 

[PhillyGuy]

Pathology is actually very competitive. Do you know how hard it is to get one of those spots?

 

[silas2642]

Pathology smells bad.

 

[deuist]

This is just plain wrong. Radiology plays a central role in the diagnosis of numerous diseases.

Radiologists can only say, "I see a mass here." They cannot tell you what that mass is. Only a pathologist can diagnose the disease through a biopsy.

 

[deuist]

Pathology is actually very competitive. Do you know how hard it is to get one of those spots?

You must be a troll. There is a 1.5:1 ratio of spots to U.S. applicants for pathology. For 2006, 92% of American seniors that listed path matched into the field. Also, 45 spots went unmatched---even after the IMG's were considered. Path is not competitive.

 

[forbin]

Obviously this comparison excludes therapeutic radiology where you zap patients with radiation. Any thoughts on why there's such a big divide?

"Therapeutic radiology" is actually radiation oncology, which is a completely different field and residency.

Radiology does offer the possibility of being an intervential radiologist and doing lots of procedures, including angiograms, CT and ultrasound guided drainage of abscesses/fluid collections, feeding tube and PICC line placements, among other things.

As far as pathology, there are some difference from radiology that I can think of: 1. much more time spent in a lab, 2. more time working with your hands dissecting specimens, doing autopsies, making histologic slides, 3. almost no acuity (i.e. there is almost never any final pathology results for at least a week or so).

 

[angel80]

I've always wondered about the discrepancy as well. I think money has a lot to do with it. Also, pathologists are definately stereotyped as being more introverted and "dorky", while radiologists don't have that stigma. I've done both Radiology and Pathology rotations in med school, and I think that the stereotype is somewhat true. Although the pathologists were all pretty friendly, they were not people that I would ever go out partying with on a Saturday night.

 

[bbas]

I've always wondered about the discrepancy as well. I think money has a lot to do with it. Also, pathologists are definately stereotyped as being more introverted and "dorky", while radiologists don't have that stigma. I've done both Radiology and Pathology rotations in med school, and I think that the stereotype is somewhat true. Although the pathologists were all pretty friendly, they were not people that I would ever go out partying with on a Saturday night.

Why would there be a "stigma" associated with being introverted? You make it seem like introverts are somehow inferior to extroverts or something.

As far as the original question, I agree that money is probably one of the main reasons. Also, from what I understand radiologists can have some patient contact especially in interventional radiology. I don't think pathology EVER has patient contact.

 

[debvz]

Also, from what I understand radiologists can have some patient contact especially in interventional radiology. I don't think pathology EVER has patient contact.

As a 4th yr student on a surg path elective, we did FNA's of nodes/masses on patients, and did immediate "wet reads" on those.

 

[Gut Shot]

Radiology plays a central role in the diagnosis of numerous diseases.

Heh heh, sure thing, buddy. If the radiologists gave the pathologists a nickel every time they miscalled tumor size, type or invasiveness, their respective earnings would be about equal.

 

[Gut Shot]

I don't think pathology EVER has patient contact.

Well, you think wrong. It's possible for pathologists to have zero patient contact, but (as debvz noted), cytologists perform FNA's, bone marrow biopsies are done by pathologists at some institutions, and blood bankers actually do crazy things like interact with patients at apheresis, do consults on the floors, go on rounds, and work in OR's and clinics.

 

[Gut Shot]

3. almost no acuity (i.e. there is almost never any final pathology results for at least a week or so).

Remember this when you're on surgery and they call for a frozen section.

Oh, and we turn around most stat biopsies the next day, thank you very much.

 

[bigfrank]

Hey Folks,
With any luck, I'll be starting medical school this fall. From reading all the threads on this board, I notice that radiology is a very popular & competitive field. Yet pathology seems very unpopular. From my limited outside perspective, it seems like they're pretty similar fields, with similar work demands. Most of the day, you sit in a cushy chair and look at pictures and figure out what's going on in the patient. Obviously this comparison excludes therapeutic radiology where you zap patients with radiation. Any thoughts on why there's such a big divide?

To answer your question (please ignore the idiotic posts on this thread), the reason that radiology is more competitive than pathology is that radiologists tend to make 50-100% more than pathologists. Radiologist work more hours for their paycheck though. The difference in competiveness doesn't have a great deal to do with perception or societal prestige, in my opinion.

This is also why dermatology is much more competitive than radiology -- similar pay but dermatologists work fewer hours per week with little or no call.

 

[cdql]

That's exactly what I said.

 

[deuist]

Oh, and we turn around most stat biopsies the next day, thank you very much.

Also, much of the reason for the wait is the processing time involved in getting a sample stained and ready for proper viewing.

 

[Taurus]

Maybe after the cuts in imaging reimbursement go through next year, radiology will end up looking like pathology after all, not very competitive at all.

 

[Biscuit799]

The difference in competitivness is pretty much strictly about money. First, the only reason a specialty could possibly be more competitive is because more people apply to positions in that specialty. Thus the top candidates will have higher numbers, etc simply bc there are more of them. Given this, the most competitive specialties are plastics, ortho, derm, optho... and what are the highest paying specialties? That's right plastics, ortho, derm, optho. And what are the least competitive specialties? FP, IM, peds. And what are the worst paying specialties? FP, IM, peds. So while it's really cute that we as med students aren't in it for the money and strive to make humanity better, when it comes down to it, we'd all take the 400K/yr paycheck over the 90K/yr one.

And yes, I might be a little cynical...

 

[cdql]

I don't think that's cynical. It's smart! Who in their right mind would chase after the 90K paycheck when there's a 400K paycheck out there?

That being said, another poster mentioned that reimbursements may get slashed for radiology (and for any other field for that matter). No one can predict what the market will be like when you get out and start practicing. So using money as the sole factor for deciding on a career might not be the wisest choice. A good balance of interest and $ is probably the best way to go.

(Of course, if you do happen to have an interest in derm, optho, ortho, or plastics, I doubt the reimbursements for those fields will ever drop them in the lower-paying specialty tier. Good choice! 🙂)

 

[TheMightyAngus]

I don't think that's cynical. It's smart! Who in their right mind would chase after the 90K paycheck when there's a 400K paycheck out there?

ineffectual white liberals?

 

[cdql]

ineffectual white liberals?

You'll notice I asked who in their RIGHT mind would take lower pay. 😀

 

[qwopty99]

don't do radiology, unless u want your job to be outsourced to some foreign-trained MD in bangladesh. ask any radiologist what the hot topic at radiology conferences are: the advance of digital mediums may render many north american jobs obsolete.

the field of pathological medicine, while it will inevitably be prone to some changes in the way it will be delivered, by its very nature will remain much more resistant to obsolence due to technological advances.

bottom line: current $$$ is in radiology. but pathologists have the job security...

 

[Law2Doc]

Radiologists can only say, "I see a mass here." They cannot tell you what that mass is. Only a pathologist can diagnose the disease through a biopsy.

But the pathologist can't tell you squat without some sort of invasive procedure (such as the biopsy you suggest).
Radiologists have better toys, so they can charge more to let the other doctors play with them. And they no longer just sit in a room looking at films -- interventional radiology is drawing more of the proactive types into the field too.

 

[Law2Doc]

don't do radiology, unless u want your job to be outsourced to some foreign-trained MD in bangladesh. ask any radiologist what the hot topic at radiology conferences are: the advance of digital mediums may render many north american jobs obsolete.

Litigation issues make this a non-concern. No hospital is going to go in front of a jury and say that a mistake was made someplace overseas and that no US licensed radiologist in the hospital ever read the film. They can have foreign places do the initial read, but to farm it out completely is litigation suicide.

 

[Gut Shot]

But the pathologist can't tell you squat without some sort of invasive procedure (such as the biopsy you suggest).

If it's your ass on the line, would you rather have a shot at a definitive diagnosis or a laundry list based on how some mass appears on different phases?

Radiologists have better toys, so they can charge more to let the other doctors play with them. And they no longer just sit in a room looking at films -- interventional radiology is drawing more of the proactive types into the field too.

They have more toys, to be sure, but the situation is becoming what I consider to be a dangerous level of reliance on technology that frequently turns out to be dead wrong.

Example 1: AAM in 50's notices upper abdominal mass. Goes to VA and has a CT. CT shows huge retroperitoneal mass that is invading everything around it. Surgeons decline to even do an ex-lap. AAM goes to different VA in another state for second opinion. More aggressive surgeons do an ex-lap and find an encapsulated sarcoma that is adherent to one point on the abdominal wall by a little peduncle. Snip snip.

Think this is unusual? It happens all the frickin' time!

Example 2: AF in 30's presents with suprarenal mass. Rads waxes poetic about the large area of central necrosis and the extensive IVC invasion. Surgeons attempt to send her to another hospital for complicated resection effort - they decline. She comes back and somebody musters the gonads to do an ex-lap. Guess what? Venous invasion? None. Necrosis? None. Path eval pending.

 

[Law2Doc]

They have more toys, to be sure, but the situation is becoming what I consider to be a dangerous level of reliance on technology that frequently turns out to be dead wrong.

No question it comes down to the person working the machine rather than the machine itself. The same kind of arguments have recently been made in all the med journals about the decline and deterioration of physical examination and stethescope skills in the wake of current tests.

 

[txguy]

No question it comes down to the person working the machine rather than the machine itself. The same kind of arguments have recently been made in all the med journals about the decline and deterioration of physical examination and stethescope skills in the wake of current tests.

A Radiology resident I recently shadowed said the CT is the new physical exam....I found that very interesting!!

-tx

 

[Gut Shot]

No question it comes down to the person working the machine rather than the machine itself.

The problem isn't the interpretation. Everybody sitting in tumor board, regardless of discipline, can stare at the CT scan and agree with what the imaging shows. The problem is that what the imaging shows often has little in common with reality.

I did an autopsy a few weeks ago on a patient who was known to be riddled with cancer. The abdominal CT detailed numerous liver masses up to 1.8 cm in diameter. I cubed that damn liver looking for said masses. Didn't turn up jack squat.

Sigh.

 

[1Path]

But the pathologist can't tell you squat without some sort of invasive procedure (such as the biopsy you suggest)

Real easy to say that until the day the unknown mass is found in YOUR body. Would you want someone to "look" at it or "look" at it, cut it out, and "look" at it again?

 

[Law2Doc]

Real easy to say that until the day the unknown mass is found in YOUR body. Would you want someone to "look" at it or "look" at it, cut it out, and "look" at it again?

I don't understand your post. The biopsy can still be a step in the process, but is invasive and thus often needn't be the initial step. You can rule out a lot of stuff with imaging, Havarti's valid concerns notwithstanding.

 

[deleted87716]

I don't understand your post. The biopsy can still be a step in the process, but is invasive and thus often needn't be the initial step. You can rule out a lot of stuff with imaging, Havarti's valid concerns notwithstanding.

Could it be that everyone has a role to play in the diagnostic process, and that no one specialty is more or less important in the overall scheme of things than any other?

Besides, if it weren't for guys like me sending you cases, none of you diagnostic gurus would have anything to do in the first place. 😉

 

[Gut Shot]

You can rule out a lot of stuff with imaging,

This reminds me. We just had a tumor board where the imaging "ruled out" hepatocellular carcinoma. Never mind that there is no discernible mass outside the liver, and the patient's AFP level is sky high. Last I heard the plan was surveillance. Hopefully we can sort out the real story at autopsy.

 

[deleted87716]

Last I heard the plan was surveillance.

Sounds odd. I'm assuming that somebody thinks a biopsy would be too high-risk for some reason?

Most autopsies are performed too late, IMO. 😉

 

[Law2Doc]

This reminds me. We just had a tumor board where the imaging "ruled out" hepatocellular carcinoma. Never mind that there is no discernible mass outside the liver, and the patient's AFP level is sky high. Last I heard the plan was surveillance. Hopefully we can sort out the real story at autopsy.

Sadly, there will be many, many examples of mistakes in virtually every specialty. Machines with better resolution will help, but errors will always exist. This includes both radiology and pathology.

 

[Law2Doc]

Most autopsies are performed too late, IMO. 😉

They tend to be frowned upon earlier in the process. Reminiscent of the "Bring out your dead" sketch from Monty Python.

 

[deleted87716]

They tend to be frowned upon earlier in the process. Reminiscent of the "Bring out your dead" sketch from Monty Python.

When I was in residency, we once listened while a medical student presented a patient on rounds. Her findings included the autopsy results (the patient was lying in bed next to us, with ears perked up).

Of course, she meant biopsy results. Details, details.

 

[size_tens]

One factor no one has mentioned is the demand for radiologists vs pathologists. In general demand for rads is very high. It's possible to get a good job pretty much anywhere in the country with rads. I've heard that the average graduating path resident only gets 2 or 3 job offers. Given the quickly advancing state of imaging technology there's little doubt that demand for rads will remain very high for a long time. There are tons of medical equipment makers out there racking their brains trying to come up with the next $1 million essential imaging device. This sort of growth just isn't present in path.

 

[Whisker Barrel Cortex]

This reminds me. We just had a tumor board where the imaging "ruled out" hepatocellular carcinoma. Never mind that there is no discernible mass outside the liver, and the patient's AFP level is sky high. Last I heard the plan was surveillance. Hopefully we can sort out the real story at autopsy.

There are limitations to imaging that we are forced to deal with. I have never seen cases such as your wonderful "examples" of how much radiology sucks. I do know that I'm sick and tired of our pathologists, who should be the ones making the final diagnosis, giving reports that read "Inflammatory cells present. Cannot rule out cancer." Or, "features of malignancy." Yeah, the reason we did the biopsy was to figure out whether it was a new lung or a met from the bladder. If you've got 3 core biopsies in front of you, you should be able to figure it out. Thanks for telling us what we already knew. And can any pathologist ever actually make a diagnsosis on cytology. Not ours. How about the brain lesion that was biopsied. On frozen the attending called it possible malignancy so the whole thing had to be resected. Final path: Inflammatory lesion. Diagnosis MS. I could give you many more examples, but I think this is enough. Just remember, Havarti, the street goes both ways.

Part of my point ouf the above rant is that the point of view is often skewed by your environment. I've been extremely dissappointed with the performance of our pathologists, who actually hedge on their reports more than we do. Based on your examples, either your radiology department is not the best, or they were some unusual cases.

Now for the reasons for why rads is more competitive:

1. Money is definitely a factor. This will likely change in the future as radiology incomes get cut, much like pathology incomes were cut in the early 80s.
2. Availability of positions. Radiology is in high demand throughout the country. No problems finding a job anywhere. From what I have heard (correct me if I'm wrong), the path market is tepid.
3. High tech gizmos.
4. Procedures. Contrary to what some people believe, most general radiologists, not just interventional rads, do a decent number of procedures. Obviously the interverntional guys do many more and more complicated procedures. This has drawn an applicant pool to radiology that wouldn't even consider pathology.

 

[Gut Shot]

If you've got 3 core biopsies in front of you, you should be able to figure it out.

Depends on the quality of the material. Last week I got a liver biopsy that was all lung tissue. Am I to blame? Sorry, as much as we'd love to make chicken salad from chicken ****, it's just not possible.

At least if we say "inflammatory cells present" you can be sure that inflammatory cells are indeed present.

 

[slackerjock99]

The difference in competitivness is pretty much strictly about money. First, the only reason a specialty could possibly be more competitive is because more people apply to positions in that specialty. Thus the top candidates will have higher numbers, etc simply bc there are more of them. Given this, the most competitive specialties are plastics, ortho, derm, optho... and what are the highest paying specialties? That's right plastics, ortho, derm, optho. And what are the least competitive specialties? FP, IM, peds. And what are the worst paying specialties? FP, IM, peds. So while it's really cute that we as med students aren't in it for the money and strive to make humanity better, when it comes down to it, we'd all take the 400K/yr paycheck over the 90K/yr one.

And yes, I might be a little cynical...

1. 400k, 8-5pm.
1a. 800k, interventional rads
2. limited patient contact
3. your date likes the sound of radiologist

 

[Whisker Barrel Cortex]

Depends on the quality of the material. Last week I got a liver biopsy that was all lung tissue. Am I to blame? Sorry, as much as we'd love to make chicken salad from chicken ****, it's just not possible.

At least if we say "inflammatory cells present" you can be sure that inflammatory cells are indeed present.

Nice try trying to blame someone else again. I geuss you are in need of more examples of pathology blunders. I go to autopsy conference on a patient. Died of unknown causes. I ask if they found, or looked for the lesion in the liver. Their response: "There was a lesion in the liver?" Maybe they should actually look at the patients records before the autopsy.

We make many diagnosis that don't ever get to you. Get over yourself and give us an answer on cytology instead of asking for more sample after the 5th pass.

The key to radiology, even if we are fallible, is that we make these diagnosis before the patient has to be filleted open or die. If you can tell the surgeons that that huge mass surrounding everything is just attached at one point using your microscope before he takes it out, go right ahead.

 

[slackerjock99]

Nice try trying to blame someone else again. I geuss you are in need of more examples of pathology blunders. I go to autopsy conference on a patient. Died of unknown causes. I ask if they found, or looked for the lesion in the liver. Their response: "There was a lesion in the liver?" Maybe they should actually look at the patients records before the autopsy.

We make many diagnosis that don't ever get to you. Get over yourself and give us an answer on cytology instead of asking for more sample after the 5th pass.

I love these lovers quarrels. I think i'll be a very happy man as a part time dentist / golfer.