Crowdsourced Advice for Being a Young Radiology Attending

When I was serving as chair of the Texas Radiological Society’s Young Professional Section, I surveyed practicing radiologists about the transition between training and independent practice. This collection, along with other career advice, is collected on the YPS page of the TRS website.

Here are some highlights from their advice:

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On the Single Biggest Surprise of Being a New Attending:

• Being alone and not being able to get “the answer” from an attending
• The pace of private practice
• Difficulty in advancing the practice’s agenda when most radiologists focus myopically on themselves rather than strategically on the practice (which ultimately benefits them more).
• How long it takes to create a decent lecture
• How much effort it takes to work with a bureaucracy to accomplish even simple changes, even if it is obviously better for the patient and the institution. (Try to focus on the positive monetary aspect early in the discussion.)
• I had a lot of on-the-job training, much of it on my own, to learn new skills. It also takes an effort to keep old skills intact. Being versatile has been valued by my practices (have had two jobs in my 30-year career).
• All practices value quantity while still valuing quality. All attempts at increasing efficiency are necessary. Several recent new junior members in our practice were not prepared for this (even with our low modest productivity requests, which we ask them to ramp up to over six months).
• How much I was not respected by other attendings.

On Making an Impact:

• Don’t be afraid to ask for help.
• Business acumen will not compensate for a lack of clinical acumen.
• Remember that your clinical work impacts patients.
• Build consensus. Kotter’s 8 steps. It’s hard but it works.
• Double-check your ideas (in multiple ways including assessing from other points of view) before you espouse them so that you will have answers to the questions or objections that will likely come–then you will be legitimately known as a thoughtful contributor, a valuable resource, and someone worth following (i.e. a leader).
• Engage your referring physicians. Call them. Go to meetings–even after hours. Become a leader by just showing up and participating–no special skills required.
• Do your best, be fair and honest, and life will reward you.
• Don’t just read films. Participate in the business, learn how to run meetings, and fix things that need fixing to ensure great patient care.

On Learning from Mistakes:

• Humility is key.
• Admit them readily–to others and yourself.
• Don’t assume that rank-and-file radiologists will look beyond their worklists and their paychecks.
• Try to be careful–but you WILL get sued. Going extra slow or being too cautious or hedging will not help. Getting sued is sort of random, and it is not the big misses that usually cause litigation.
• Don’t be afraid to ask for help from those who are better at a given modality or disease than you. Pay attention when reading out with residents and fellows.
• Self-analysis as to why you messed up is extremely useful for progress but must be combined with self-forgiveness. If you don’t you are leading yourself to a dark place and will become much less productive (not to mention it’s just no fun to keep beating yourself up).

On Accepting feedback:

• Always readily consider constructive feedback.
• Don’t be defensive. Always say thank you.
• Revel in it.
• In conversation, it’s extremely hard to learn something new
  if you’re the only one talking.
• Accept feedback from the folks you respect and who you know practice great patient care. Evaluate the feedback from those who do not fall into that category.

On Becoming Indispensable:

• Understand business mechanics and actively try to improve on behalf of the practice.
• Focus on value-added activities like committees.
• You may feel indispensable in the current job market but markets come and go, and the radiologists considered most valuable will always have job security.
• It is not only important to look for things to do that you already enjoy and are good at (frequently resulting in you being considerably better than others almost without trying)…but you also need to assess whether that talent or area is going to be useful for the enterprise. Think hard before investing your limited time so that you become really good at something that most others are not.
• You need to actively look for opportunities to use your skills, and then you have to be available–able to say yes and have the time to actually succeed in a timely manner. This also means you have to learn to say “no” to other projects (quite difficult).
• Be available. Often at meetings, I will remind my referring physicians and trainees to call me BEFORE ordering an exam to discuss the best options. I truly like these phone calls. Most referring providers feel that they are bothering me–and I remind them that they are not.
• When someone shows up in your reading room (rare nowadays), stop and address them immediately. But I also always say, “I don’t take orders, I take requests.”

On When to Say Yes and No:

• Early on, always say yes. Later, rarely say yes.
• At some point, it’s easier to subtract than add to an already full plate.
• Figure out what you want to do with your life and what you want your legacy to be. Use that as your guidepost.
• When you answer “yes,” you must realistically have time to do the task in a timely manner. Learning how to not fool yourself on this is very difficult–so practice this skill early in your career (like starting yesterday).
• When saying ‘yes’ starts causing problems in the practice or at home, re-evaluate your commitments.

On Avoiding Malpractice:

• You can’t avoid it. The majority of radiologists get sued at least once during their careers. If you do get sued, make sure you have a good attorney and work closely with him/her. After you perseverate on your case, no one will know it, the literature, and the nuances better than you. No one has more at stake in engaging in the defense than you.
• Be informative, friendly, and honest with your patients. And then don’t think about it.
• Do your best when reading: take your time and look at old comparison studies.
• Everyone makes mistakes, but not every really cares enough to try not to (reading the history, reviewing the priors).

On Building Relationships with Clinicians

• Customer service is more than clinical competency. You should be half physician, half hotel concierge.
• Good referring relationships will make your job much more professionally rewarding. And, if things go badly for your group, having advocates outside the group could be invaluable.
• Ask them questions about the most important things they need to know concerning the various imaging exams that you are doing/interpreting for them.
• Learn what they do (a long process). For example: briefly read about their procedures before you ask them questions. They will come to you if they know you understand them and care about doing it right.
• This has become more difficult over the years. At first, clinicians came down to ask for opinions often. With PACS it has decreased, so attend multidisciplinary conferences.

On Learning on the Job:

• An active pursuit. Learning doesn’t stop when you finish training.
• Find a mentor to help. Have go-to people that you lean on for different kinds of modalities/cases/pathologies.
• Pay close attention to how others do the tasks and steal what you like; why reinvent when you can “cheat”?
• When you don’t understand why someone did something in a particular way, ask in a way that is complimentary to them & their skill.
• Go to meetings. I love big ones like RSNA, but you need to be prepared in advance. If I am not learning in a session, I leave. Read the journals, a little every day while in early practice.
• Continuously learn, from CME, from cases online, from colleagues, and from clinicians. A new disease? Read up on it.

On Navigating Office Politics:

• Try to avoid getting too mired in internal politics. Instead focus on politics between the group and the hospital, and try to improve on behalf of the group.
• Listen and reflect before you speak.
• Direct confrontation is rarely the best approach (but occasionally necessary).
• Focus on how your ideas will help others and not how others are incredibly stupid.
• Critique the method/approach, not the person who said it.
• If you “secretly” criticize others, the person you’re discussing this will correctly conclude that you may be saying similar things about them (to others).
• Be respectful and friendly with techs, nurses, and administrators (and colleagues). They are watching you.
• Learn to run meetings. I found participating in organized medicine helpful from a young age. But when you have a boss with no leadership skills, it is difficult.

On Working with Older Generations and Dealing with Entrenched Behaviors:

• Avoid individual battles. Sell ideas to a group rather than an individual.
• The golden rule: treat others with respect.
• Older partners are selling out their younger partners left and right. Find the ones who really care and build alliances with them. Having an advocate within the circle of power can be highly impactful.
• As president of our practice, I have dealt with many such issues. Taking issues to our board of directors–with a potential plan–has worked in many cases. Sometimes, however, no matter what we do we cannot avoid radiologist misbehavior (arriving late, leaving early, dumping cases on partners, cherry picking, complaining, being difficult with techs, canceling procedures, irritating referring providers). Most practices, like ours, simply cannot fire a radiologist right now because it is so hard to recruit. We try to schedule difficult radiologists at locations where they will be less problematic or on evening shifts, etc. Gathering the group together for social events tends to diminish misbehavior and helps with relationships.
• Wait for the right time to interact. A few years after I joined my practice I tried to update our paper billing to computer-based software. Senior partner not on board because of cost. Two years later, when it was his idea, everything went smoothly.
• I learned a lot from my older generation. Some of the greatest radiologists I have ever met. Entrenched or bad behavior is not exclusive to the old. Hopefully, your group shares cases equally and some people do not cherry-pick easy cases.

On When and How to Quit:

• Stay with work that provides you with purpose and positive energy.
• It’s easy in the current gerbil wheel world to look elsewhere but the grass isn’t always greener. Key signposts to say you should seriously consider quitting: do you trust the people you work with? If the answer is no, run fast. But always take the high road going out. Radiology is a small world and people talk.
• Neither “pedal-to-the-metal” until you keel over or just go “cold turkey” are usually the best approaches. Tapering is good.
• By this time you’ve figured out the two things that you probably want to spend more of your time doing in your later years (what you are best at & what you enjoy). See if you can swing it that way, and you’ll not want to retire as soon.
• Tapering allows you time to still do some of the work things you didn’t have time for earlier and enjoy non-work activities more. But there’s nothing wrong with quitting cold turkey either and immediately enjoying all the other things you’ve been wanting to do (as long as you’ve followed sound economic/investing advice throughout your career).

Overall, what do you wish you had known during your first few years in practice? What advice would you give your younger self or others?

• Most of your attendings in training were really good physicians and people. Practice what they taught you. Pursue independence above all else in practice (business, clinical decisions, etc).
• It is unlikely your first job will be your last job.
• Knowing more about leadership principles, negotiating and consensus building and the business of radiology will help you a lot in most groups.
• Work on how to get your point(s) across in a strong collaborative (non-combative) way, in the most concise fashion possible. Only mention the most important points and leave nearly all details for later discussion (if your audience wants/needs it).
• Read books, go to courses, find a mentor…whatever it takes, since this is key to becoming a good leader and accomplishing the things you think are important.
• Try to model best work practices. Create good reports. Ask the techs and nurses for feedback. How can I do a procedure better? My standard advice to young members in health care when doing procedures: “Be quick and confident” (not necessarily in that order). Patients don’t need to be poked and prodded longer than necessary. Make your patients feel that you are highly skilled and confident that this will go well.
• Things get better and you will find your niche.
• Participate in organized medicine to learn about your profession. Don’t assume the billing folks are doing things correctly.
• There is never a second chance to make a first impression at a new job.
• Become really competent at something highly useful. Absolutely work hard so you can make a strong positive impact with your efforts/life: a fulfilling life’s work.
• Make sure that you have also reserved time for the other important/enjoyable things in life. Learn and practice the art of saying “no” early in your career.
• Develop efficient work habits, such as being concise in your communications.
• Work hard, but not to death. Remember your family. Always take care of your patients.

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Feel free to add your advice in the comments.