Considerations for Your First Job in Radiology

The majority of radiology trainees will take jobs in private practice, but whether academics or PP, there are still a lot of details that will significantly change what your job is actually like and what you should consider in choosing.

This post is very long (~3600 words), but I don’t feel like trying to publish it as a 10-part-series for more clicks. Refill your coffee or tea and let’s go.

 

Practice Setting

I’ve written previously about the differences between private practice and academic radiology, and I still largely agree with myself and that think post is worth reading. Go ahead, I’ll wait.

Private Equity

I don’t really want to get into this topic too much here. PE firms like to gobble up practices in a tight geographic area such that they can achieve local market dominance and then negotiate for higher reimbursement. Local monopolies are a business model. However, the easiest way for them to make money for their investors after a leveraged buy-out is by hiring more young people fresh out of residency for whom any attending salary seems high and using that relatively cheap labor to replace the older higher-paid partners that will soon be retiring on the cash (and potentially stock) from the buyout in a few years when everything vests.

If you need to live somewhere and that’s the shop in town, so be it. It’s not as though there aren’t bad groups that aren’t owned by private equity.

But on the whole, I think doctors do better for themselves and their patients when their personal and practice interests align. While you may have a limited voice as an individual radiologist working in a large group, an independent practice itself can choose its priorities and how those align for optimal patient care. A third-party middle man dictating how much, how hard, and how fast you work over the long term is ultimately dictating how you practice medicine. I don’t think that’s good for our profession.

If you’re interviewing at an independent group, I would absolutely discuss the issue of a practice sale with them and see how they respond. Being in the work-up during a buyout is frequently a crappy situation to be in, where you’ve put in sweat equity only to have the benefit rug pulled out from underneath.

PE firms got a lot of bad rap in the news recently for things like surprise billing, and there’s an excellent reason for that. It’s because they deserve it.

[For further reading, I subsequently published a dedicated essay on private equity in medicine that you might enjoy]

Nighthawk & Teleradiology

Strict teleradiology is overall probably not an ideal first job after training. Being alone (and often production-based) fresh out of fellowship could be pretty lonely, disorienting, and stressful.

Night gigs are tough. Burnout is high and most people can’t maintain it for more than a few years. I’ve heard it can sometimes be hard to land a normal day job for some folks after a period of tele nights, and many groups treat their internal nighthawks as sort of second-class citizens. Typically the schedule and pay are good on paper, often 1 week on 1 week off (sometimes 1-on 2-off, which sounds much more sustainable), but it’s not uncommon for nighthawks to be strictly non-partnership-track employees with no avenue to transitioning to day work when you’re burnt. If you’re considering an internal nighthawk job, I would try to find a group that will work with you on these key details.

My group for example has a three-week rotation for our night radiologists where they work one week of days, one week of nights, and one week off. This way they’re part of the group and also do some regular work with other humans during normal human hours.

That said, there are people from whom this lifestyle is a perfect fit. If this is your plan you need to exhaust all of the options because not all remote work is created equal
(including both local group coverage and actual teleradiology companies). The case-mix and RVUs of an average shift vary widely. An 8-hour shift reading 60 RVUs is a completely different gig than 10-hour 100 RVU churns, even if you’re working 1-on-1-off.

Location

Many residents/fellows will take a job locally, which likely reflects a combination of inertia and true preference. These sorts of opportunities are more straightforward to find and feel out. When groups are hiring, they typically reach out to local programs and will often be able to vet you through their personal contacts (even if those aren’t the people you’ve listed as your references). For your benefit, you’ll likely know (or can be put in contact with) former residents working at these groups that can give you the low down. Interviews won’t require travel. The whole thing will hopefully be pretty straightforward.

Finding nonlocal jobs may require a bit more work to suss out good opportunities. Some but not all positions will be posted on the ACR Career Center. Consider joining the American Radiologists Facebook group (and probably RadChicks for female rads), where openings also sometimes appear (and where you can query the hive [even anonymously] with job-related questions). I grabbed a body imager for our group via Facebook last year. This is the world we live in.

For better or worse, COVID means that a lot of groups are interviewing virtually. If you know what you want (say you really want to be a certain location and only one group is hiring), then this will at least be convenient, but overall I think it makes things harder in terms of assessing fit on both ends. Regardless of interview modality, you need to find some junior people in the group who have been there 0-2 years (or someone who just made partner if applicable) to talk with. Hopefully, that’ll be part of the interview process but these folks will provide you with an important perspective. Ask questions.

Procedures

It is increasingly common in large cities with hyper-consolidated markets for IR to do basically all body IR and vascular IR procedures. Even in the common situation where others (such as a neuroradiologist) may perform inpatient lumbar punctures and myelograms during the day, it is not uncommon for any after-hours LPs to also go the way of the interventionalist. Smaller groups may still have general radiologists who perform a variety of nonvascular interventions like abscess drainages, and it’s still very common for groups to need the random rad on-site at various imaging centers to take care of the usual bevy of LPs, myelograms, arthrograms, and joint injections that may be scheduled there. But it’s also common for centers to schedule specific exam types on the days where the relevant subspecialists are covering or to only schedule certain types of procedures at specific centers. Most groups that need such coverage will ask you if you’re comfortable doing the things they need you to do. (If you’re not and you want to work there, the answer is that you’re happy to (re)learn).

Many academic groups also split procedures up by subspecialty such that a neuroradiology fellow would likely perform more spine biopsies and injections during training than they ever would once out in practice, where this may be handled by either interventional or neuro-interventional radiologists. Where I trained, for example, every division handled their own procedures, with the exception of lung biopsies, which switched from chest to IR during my first year in my residency. The bottom line is, it varies. And while this is subject to change, you should at least be aware of your comfort level and interests and the expectations of any group you look at.

For example, my fellowship was relatively procedure heavy, and I could easily be credentialed in the full gamut of spine interventions and pain injections, but in my actual practice, I do LPs, myelograms, GI/GU fluoroscopy, arthrograms, and joint injections. Meanwhile, our mammo is 100% performed by breast radiologists (whereas some places want everyone to do some breast imaging).

The broader your skill set, the more marketable you will be in general because different practices have different needs. But in real life, your practice may or may not be considerably more narrow. There’s also a decent chance that your first job won’t work out for one reason or another, so you could easily find yourself in a different situation doing some CME course and watching YouTube trying to brush up on skills you let atrophy. I once knew a 100% subspecialized academic MSK-radiologist who after like 7 years of practice transitioned to a nighthawk ER job to be able to spend more time with her kids. These things happen.

Salary & Vacation

Depending on any geographical constraints you may have, the details of group logistics may be moot. If you need to work in a certain city and there are three major groups of which only one is hiring in your subspecialty, then you will likely take a trap regardless of the size of the buy-in or if you think the call is equitable for people in the work-up.

Even more than salary, vacation is often the biggest measurable difference between academic practices and most private groups. Somewhere in the range of 8 to 12 weeks off is not uncommon in radiology private practice with less “desirable” locales sometimes offering even more (I’ve seen as high as 20 weeks at least several years ago, which is bonkers).

Large metros have seen a lot of consolidation over the past decade, and there are generally very few small groups left. The smaller groups where everyone practices as a complete generalist and does all the “light IR” are much more common in smaller cities and rural areas. Likewise, the consolidation and competition for imaging contracts have also pushed salaries down in big metros. You’re generally going to make more money with more vacation in a non-premier location within a region as well as in certain regions of the country more than others (e.g. midwest > coasts).

Your employee pay will definitely vary, but in many cases, it’s really the partner reimbursement where you’ll typically see the greatest spread. Whenever you evaluate money, make sure to include 401k profit-sharing contributions, group contributions to a health savings account (HSA) for high-deductible health plans, and other such non-salary compensation. These add up and can make a huge difference.

Partnership

In private practice, partnership is a big deal and you need to evaluate exactly what partnership means in your group, how long it takes to get there, and what buy-in you’ll need once you do. Some groups are completely democratic where all partners have a vote in major issues, all are eligible to serve on the board of directors (if there is one), and all get paid the same amount of money for the same amount of work, have the same amount of vacation etc. Others may have a tiered partnership similar to some law firms, where junior partners basically get a salary increase but senior partners still skim the cream financially and make the decisions. Still others are actually owned by private equity or another corporate entity and a “partnership” may or may not mean very much.

Some older radiologists may tell you that if a partner-track work-up is longer than a year then it’s BS and you should look elsewhere. That is unfortunately not the case in many markets, where you can easily expect tracks as long as 3-years. While the radiology job market is still much better than it was in the mid-teens, competition for hires is I think very unlikely to bring things back to what was common during the golden age of radiology reimbursement.

I also want to make it clear that an employed (non-shareholder track) position is not inherently bad. In some cases, an employed position can be more flexible and not have the same call responsibilities, can be part-time, or sometimes even get paid more (upfront) than a similar partner-track position in the work-up. In other groups, all non-partner employee jobs are the same whether you make partner after the prescribed amount of time or not. It’s absolutely possible to work for a good group as an employee just as it’s possible to be a partner in a crappy group.

If you’re in a group that offers both types of positions and decide to try to switch to partner-track, classically the work-up clock resets. Getting credit for time served is a point very much worth negotiating.

Buy-in

In most radiology practices, employees in the workup are already paying into the practice for the shareholders via sweat equity: you make less (and often have less vacation) than a partner for a period of time, and the group makes money off of you by paying you less than you bring in via production. Buying actual “shares” in the practice is usually on top of that, and the buy-in sum depends on the assets at stake. In a group without real estate/imaging centers, your buy-in is essentially for accounts receivable (the amount of money the group has earned/charged but hasn’t yet received). An AR buy-in will depend on the size of the group but should typically be in the five-figure range. A six-figure buy-in should start containing something more substantial.

The buy-in cost can often be financed by the group itself so that part of your new higher partner salary goes toward paying for the buy-in. In this case, your income bump will be attenuated for a while after you make partner.

If the buy-in is super high but the group’s assets suck, this is usually a way to get young partners to overpay for their slice of the pie, give the group more cash on hand, and then fund the exit-packages/retirement of the retiring partners when they sell their shares back to the group.

In general, a large democratic group is going to be more likely to have a fair valuation and should always share the numbers they use to derive everything. Theoretically, your buy-in should basically be the value of all the group assets (buildings, scanners, etc) divided by the number of partners (or the number of total shares multiplied by the number of shares you purchase when you become a partner). There shouldn’t be secrets. If the number makes you uneasy or you think the valuation of the assets looks too high, have someone evaluate the deal. You don’t want to be paying luxury car prices for a used Ford Pinto. And, at least to me, shady accounting is a red flag.

That said, your true “buy-in” isn’t just the lump sum you pay when you become a partner but is the combination of that and the difference in salary and vacation during the workup period. This can actually be hard to really define since partners are usually paid in a combination of salary, potentially “call pay” for working evenings and weekends, and profit-sharing. Suffice to say that employees are good for the group’s bottom line.

Going Part-time

One potentially important consideration that people often don’t discuss is how the group handles part-time work. Some groups allow partners to go down to 80% or sometimes as low as 50% time while still maintaining partnership status (you typically pay back your portion of the salary and benefits as a fraction of the full-time equivalent total). In these cases, it’s possible to continue making the same amount (or more) than you did as an employee while working considerably less.

Other groups don’t, which means that if you make the choice to roll back your hours in the future, you may need to do so as an employee of the group instead of a shareholder, typically a big hit to your reimbursement even on a pro-rated per-hour basis. In some cases you might also get less vacation than you did as a partner, negating some of the benefits of going part-time in the first place.

For reasons I don’t fully agree with, many groups are optimized for partner income and not set up to account for lifestyle flexibility. If you think you might want to work part-time at some point in the relatively near future, choosing a group that does not meaningfully allow for this may be a mistake.

Timing & Interviews

Try to interview at 3 or 4 places to be able to compare possibilities and make an informed decision. Know that it’s very common for a group to request an answer to a formal offer ridiculously quickly. At one group I was given a response deadline of 6 days! So know that you’ll need to cluster interviews if possible. You also just need to be honest with groups. If you have another interview the following week and you get an offer that’s asking for an immediate response, be gracious, thank them, and ask for more time. Don’t get muscled.

In recent years at least, lots of folks have started looking for jobs in the summer as fellowships started and had locked in jobs by early fall. While good positions may open up later, don’t wait to start looking.

As for the interview itself, you’ve done this a few times now. The same rules apply. In a large group, you may do most of your upfront communication and coordination with a practice administrator or even a dedicated practice recruiter. You know, be nice. If you’re interviewing somewhere academic, you’ll be giving a resident lecture, so prepare one that doesn’t suck.

Contracts & Negotiation

Offers will often come in three stages:

1. Verbal
2. Letter of Intent or Letter of Understanding
3. Contract or Employment Agreement

Verbal agreements are supposed to count, but memory is imperfect. Get everything important to you written down.

The Letter of Intent is a short binding contract, often 1-2 pages, that in many cases is the only document that actually specifies the core details of your job, such as your salary, vacation, section/division, and often (current but subject to change) call responsibilities. Make sure everything important is in there before you sign it. If you want something spelled out in writing, in many cases it will actually make more sense for it to show up in a Letter of Understanding than it would in the formal Employment Agreement (which will often reference the Letter).

In many radiology practices, the Employment Agreement is standard across the group and will be the one document of the three that’s written in legalese. It typically details boring important things like how the group handles non-competes (aka “restrictive covenants”), grounds for termination, intellectual property, malpractice insurance, etc. You need to understand this material, and if you don’t, you need to hire someone who can translate.

As a practical matter, there often isn’t a lot of wiggle room on the main numbers for a large radiology group as compared with what your clinician colleagues often deal with. Salary and vacation are typically standard. Buy-in will also be set at the time of signing. Even most of the paperwork details like non-competes are often going to be universal to the group and therefore completely non-negotiable. If every partner has agreed to something, you’re probably not going to get out of it. A one-time signing bonus, however, will often have some wiggle room, especially if you’re coming from somewhere far away and could use extra help with moving expenses.

If you have intellectual property or plan to develop any, please be careful how that topic is described in your employment agreement. Academic centers, for example, particularly love to include heavy-handed language that they own everything and anything you come up with while employed, even when you do so outside of work hours. Likewise, while you may or may not be able to change a non-compete (and the group may or may not actually try to enforce it), the exact language will define how limiting it can be. Is a 5-mile radius defined from the group headquarters, from the main hospital(s) you read for, or from any imaging center you contract with? Because the latter will typically end up excluding the whole city.

I would argue the most important thing that you can negotiate is the makeup of your clinical duties. What fraction will you practice in your subspecialty? What procedures will you perform? Which hospitals and imaging centers will you cover? Will you read breast? If there is more than one divisional call-pool, which one(s) will you be in? Do you have to work nights? What’s the evening/swing shift and weekend burden? What fraction if any can be done from home? If there’s internal moonlighting, what types will be available to you?

To be clear, some or all of these types of details may be part of the job offering itself or equitable across the group, but I would venture that most people fixate on measurable things like salary size when comparing jobs and not nearly enough time evaluating the actual job.

There is no job in radiology that is so poorly paid that you can’t make a good living, but there are jobs so miserable that you can’t enjoy your life.

Again, while many details may not be meaningfully negotiable, these sorts of clinical parameters are worth discussing and feeling out. Don’t assume. Likewise, if you get promised something, get it in writing. You don’t want to be told you don’t have to cover some remote outlying hospital only to get assigned there the moment you show up. Your call responsibilities are likely subject to change, for example, but one thing to consider asking about is some type of credit if your call frequency is defined in your contract but subsequently increases beyond the original threshold. Wouldn’t it be nice if working an extra day at least moved up your partnership date?

([affiliate stuff] If you’re in the market for physician contract review and negotiation help, check out Contract Diagnostics. If you’re mainly interested in comparative compensation data, consider CompensationRx, which is a cheap way to get access to the MGMA info for your practice type and location [in addition to their proprietary internal data].)

Conclusion

Good luck.

Ask questions.

I’ve had friends whose groups have been bought out by PE firms, and I’ve had friends who have then rapidly left those jobs and others who have stuck it out. I’ve had friends who have been blindsided and not offered partnership in their groups, and I’ve had friends who didn’t wait long enough to find out because they didn’t like how radiology was being practiced.

If you find yourself in a position you truly don’t like, the prospect of more money in the future is unlikely to make that job suddenly tolerable. Your most valuable asset is your time, so don’t waste it doing something you hate.