A previous reader question:

What do you think is a fair compensation ratio for pre-partner to partner pay? It seems like a lot of jobs offer a 50 to 100 percent pay bump. Is there a threshold that should be a red flag?

I don’t think there is a red flag number.

These numbers mostly reflect supply and demand (and in some cases the impact of technical fees from center ownership after a buy-in).

Part of what will feel acceptable will depend on how long the track is. So if a group has a one-year track, you can tolerate a pretty big differential, but if they have a 5-year one, that might be unconscionable. If someone has a seven-year track, I probably wouldn’t want a big differential—that’s a long time to be paid less. (Given the number of unknowns over almost a decade, I  also think it would be very hard to know if you’re working toward a healthy return on that sweaty equity over such a long period).

Part of it will also depend on how high partner pay is. If a group has truly incredible contracts or an amazing real estate portfolio, it may make sense to accept a large temporary differential to enjoy potential massive returns on that time over the long term.

So I don’t think there’s a set number for it. I think it’s more a matter, unfortunately, of the holistic view.

The reality is that if you look at private practices over the past five years, everyone has shortened their track and bumped associate pay. I think most practices, especially in competitive areas, are largely doing what they can to balance recruiting desirability and providing perks to partnership.

Especially when hiring fresh graduates, it’s also not uncommon for a practice to lose money on its new hires for a while until they get up to speed. The reality is: the practice is often investing in you upfront. Partners also take risks that associates don’t, so there have to be some benefits to being a partner.

So again to summarize: it’s all supply and demand. These are businesses, and fairness is in the eye of the beholder. Years ago, when the job market was tight, we had long tracks and big differences. We are in a different era. Tracks and pay are what they have to be to recruit, and the better the offer relative to a partner, the more desperate the need to recruit or the more challenging the competition for recruitment is. The increasingly nationwide market for teleradiologists isn’t finished having its ripple effects.

So I am entirely unwilling to say there’s a rule of thumb here. Everything is local, but even then, sometimes things are good on paper because they have to be to be competitive in the market, which might mean they’re not competitive in some other way that’s harder to measure.

There are few shortcuts to evaluating jobs, few true red flags, and no ways to entirely de-risk the big decision of where to work.

A reader question:

A lot of my attendings recommend my first job should be somewhere like academics or a hospital system where I have support if there’s a complicated case or someone to help me. Do you feel like you have that in private practice?

So I personally had/have that. Does everybody? No, it depends on the practice. I originally thought most people do, but the number of people I hear from on their second job search has informed me that this is certainly not universal.

But, overall, yes. I think the idea that academia has a monopoly on support is totally inaccurate. People can make you feel inept or give you a hard time for your inevitable mistakes in any environment (I often noticed more attending-on-attending cattiness when I was a trainee).

One key support-related question: Is there a way for you to ask people for help when you have a tough case?

There are plenty of practices now that have built-in instant messaging/case sharing features in their PACS. In this setting, even teleradiologists can share cases with their colleagues back and forth all the time so long as people are generally responsive and sufficiently pleasant.

(Call is always a bit of a different story when there are fewer people working, but this varies too. It’s often a lonelier one-person job. Texting or phoning a friend is always an option, but it’s certainly easier if people are on the outpatient list moonlighting etc and able to provide some support as needed when you’re stuck on a tough case. Being comfortable asking a colleague is, of course, a really helpful place to be psychologically.)

Yes, being in a big, vibrant, distracting reading room is probably going to feel more supportive and lively for most people. One question to answer for yourself when considering an academic job is whether that environment still actually exists. With demands for remote work and expansion of academic medical centers, even large institutions sometimes have their rads increasingly scattered to the winds. (Then, you have to ask yourself if you’ll actually feel more comfortable asking in person, potentially in front of additional attendings and trainees.)

Related and important: Do people share your mistakes with you in a way that’s not going to make you feel too bad, but still let you learn from it? Or do people roll their eyes when you have a miss but don’t tell you, potentially mocking you in front of others but robbing you of the chance to learn from it? Again, that can happen anywhere (including academics).

Ultimately, I think support has more to do with the specific job and less with the model. Every practice is  “collegial” in its job postings, regardless of the reality, and plenty of radiologists in all environments take pride in their work and want new hires to learn and achieve high performance.

I think there’s a certain bubble doctors get into due to the nature of medical education, where we think academia is where the good work happens, and the outside hospital is where the bad work happens. My perception between my experience in academia, my current privademic model, and seeing the work of other practices working in our health system, is that there is no consistent relationship between overall model and quality. Subspecialization to extent, but there are good and bad radiologists and good and bad versions of every model, including in the academy.

I do think being 100 percent teleradiology is probably overall harder to feel supported. Certainly not impossible, but just those interactions won’t all feel the same if no one knows who you are and you don’t really know anybody. Asking a name on a chat list you’ve never met before doesn’t feel the same as asking a friend or a colleague in the same room or one you’ve had dinner with.

How “supported” you feel in that setting may have just as much to do with you and your needs as what the practice provides, but I’ve seen enough young radiologists on the market to know that many people discount how isolating even local radiology can be.

When I was in training in the 2010s, there was a big push for sub-specialization. It was felt to be the future of radiology (and of course, everyone absolutely needed to do a fellowship). Observers opined that the days of the general radiologist were numbered because people needed fancier skills to deal with the increasingly complex and increasingly high-volume of complex imaging.

When the ABR ditched the original oral boards in favor of exclusively multiple-choice examinations, they pushed the final “Certifying Exam” until after fellowship and gave examinees the ability to select a portion of their testing content precisely because the idea was that everybody would be increasingly specialized, and therefore the test should accommodate that increasing specialization. (Never mind that the test was duplicative and useless—that tailoring was at least part of the attempt.)

The Flaw

One flaw in that logic is that increasing imaging volumes have increased imaging across the board. Yes, MRI and CT have disproportionately increased, but there are still plenty of plain films and ultrasounds and DEXA scans, and plenty of CTs are bread-and-butter work well within the skillset of the majority of radiologists. If everybody is so specialized and reads only in their fellowship—doing magical high-end imaging—then no one is left except the aging, near-retirement boomers to read a huge swath of high-volume, often low-RVU work. That is obviously not sustainable. The approach was inherently flawed for our times and has certainly contributed to the current shortage.

The Spectrum

Many discussions of generalist vs specialist are a false dichotomy in the sense that being generalized or specialized is more of a continuum than a binary. There are varying degrees of everything, and the shifting nature of radiology and the expectations of any given job mean that basic foundational skills can end up being important—even if they seem superfluous based on a very narrowly defined position that some radiologists, particularly in academia, find themselves in.

All points on the subspecialization continuum are available. 100% cross-sectional neuro-only? Yes. 100% subspecialized during regular weekday shifts with general radiology only on call (like evenings and weekends)? You bet. Mostly subspecialized with a daily shared pool of things like plain films? Totally. Mostly generalized with carve-outs for things like specific surgeon requests, small joint MRI, certain kinds of procedures, or breast imaging? That too. “General” may include breast imaging, or it may not.

Whatever way you think things are always done, you’re wrong. We have multiple ways to work in part because we have many different employers across 50 states, all trying to solve the question of how to best provide radiological care for patients. The fewer/larger employers we have, the fewer models we’ll continue to enjoy. (That’s one reason I like to support independent practices.)

Back to That Push for Subspecialization

There are several good reasons for increasing specialization. One is that proposed by the ivory tower: complex imaging demands greater skill, and people with more training and focus can theoretically (at least on average) provide higher-value and higher-quality care in those cases. It’s easier, on average, to be better at doing a small subset of the same things over and over again than trying to maintain a broad skillset as a jack of all trades. That narrow skillset can be brittle (all those body parts are squeezed into some tight real estate after all), but there are plenty of surgeons out there who essentially operate on one joint for the same reason.

Obviously, not every case requires marshaling our greatest diagnostic powers, but the reality is that you never know prospectively which cases do—or how to get them to the right person (please, please don’t invoke AI case assignment right now). And in many cases, retrospectively, we don’t know either. Plenty of subtle findings are missed for this reason. Radiology is the easiest field to Monday morning quarterback because the pictures are always there.

So we trade breadth for depth. This approach was once common only in academia but is now increasingly available in the broader market for several reasons—but in large part because people want it.

1. In a tight job market, many practices have had to offer more subspecialization in order to land candidates. For one simple example, an academic neuroradiologist who hasn’t read a chest x-ray in 20 years may not be willing to fill your practice’s neuro needs if you make them start reading the other stuff. So the easiest way to recruit people who are already subspecialized is to offer subspecialization.
2. Even many young people like the idea of specializing. When you spend a year of fellowship doing one thing over and over again, it’s easier to envision spending the rest of your career in a similar fashion. This can feel natural, especially since many people train in an academic environment where most attendings are similarly siloed.
3. Certainly, to an extent, a job can be “easier” in many ways because you develop and evolve your crystallized skillset faster when you’re doing the same thing in higher volume. There’s comfort there—especially when we live in a world with productivity incentives and productivity metrics, where it’s easier to hit production numbers or deal with high call volumes if you’re able to work efficiently.
4. Increasingly common productivity compensation models (e.g. flat $/RVU) encourage subspecialization because it’s easier to be fast and reasonably accurate doing a smaller number of things. This is especially true when your niche involves reading things that are higher-value, like mammograms, and you can make yourself immune to routine plain films and ultrasound. Yes, internal RVUs can mitigate some of the workload “benefits” of subspecialization, but that doesn’t change the true reimbursement value or the general nationwide trend.

Bigger Pie, Easier to Slice

Another nuance is that—thanks to regulatory demands, payor shenanigans, increasing workloads, quality bureaucracy, and recruiting/retention challenges—the increasing consolidation in the radiology space has itself enabled greater subspecialization.

A small group sharing a call burden means that everyone working alone on the weekend has to read whatever the hospital throws at them. But if multiple hospitals are consolidated into a shared worklist, then there’s enough volume and enough people working to divide out the work by subspecialty in ways that would previously have only been possible within academia.

Whereas previously fellowship training meant that the complicated cases (or the postoperative cases, or the MRIs, etc) went to the person who had done fellowship training and everything else was just shared equally, now it might mean that most if not all cases can be spread similarly.

People operating at the peak of their efficiency—which is, in many cases, more likely to occur when people have a narrow work focus—means that these large corporations, larger companies, and larger groups can also probably get more bang for their buck working with that strategy. Given the workforce shortage, any edge to getting the work done can be a big deal (also, it’s easier to squeeze a juicier fruit). For those rads in the gig economy, it’s also easier to earn a higher hourly rate when you’re reading what you can crank on.

All of this is why “body” imaging and general radiology are in such incredibly high demand—because we need people to do general radiology, especially when many radiologists have opted out.

Making General Work Pay

Long-term, this has some problems, not just because people want to practice at the “height” of their license and training, but because it’s easier to do a “full day’s work” (as measured in RVUs) reading MRIs than it is reading plain films. Adjusting the internal work values to account for the desirability of cases that nobody wants to do—the low-reimbursement, high-frustration, often tedious work of plain films and DEXA and ultrasounds—is one solution. But any change, even internally, means winners and losers. And everyone hates to lose.

The economic and spiritual degradation of general radiology has also meant that with fewer and fewer people really focusing on certain exam types, the quality of those interpretations has gone down, leaving the door open for mid-level encroachment or AI replacement of many tasks.

What Next?

The status quo isn’t going to last.

But the reality is, long-term, it’s impossible to know exactly where things will go, in part because we are at the jagged frontier of AI in radiology. It may be that the need for general radiology will continue to grow as people increasingly subspecialize and opt out of maintaining broad skills from training, older radiologists retire, and imaging volumes continue to explode.

Or, perhaps the hot job market (and fear of being inflexible in the coming AI world) will encourage some people to forgo fellowship and enough others to maintain broad skills to alleviate this pressing issue.

Or, it may be that those tasks—like ultrasounds and plain films—will be the easiest to satisfactorially offload and/or preliminary pre-draft reports from AI tools, such that we can better account for relatively low reimbursement while meeting the already acceptably low quality of those interpretations.

That being said, there’s no way to know how these tools and techniques will percolate through the broad swath of radiology tasks and radiology practices, and what radiologists’ responses to those changes will be, and what the payors responses to that utilization will be, and what the regulators will do when bad outcomes make the news, and so on and so on and so on—and therefore it’s impossible to know the ripple effects in the day to day or the broader workforce (and even later on, the radiology training pipeline).

Predictions are hard.

I would argue that, regardless of individual desires or quality differences, there are several regulatory and market forces that have pushed us toward consolidation that will be difficult to undo. And in a world of increasing consolidation, it is relatively easy to silo people into discrete boxes in ways that are not possible for small groups, especially when those people want to be siloed.

If small groups continue to thrive despite market pressures, then the model of general radiology will continue to survive.

Lastly, Fighting Automation Bias

One related question: as AI tools become more helpful, do we end up in a world where human beings must be extremely skilled in order to add value and countermand automation bias? If so, that may be the strongest and potentially most durable argument for sub-specialization.

A person who reads mostly normal brain MRIs here and there may not be able to function as an effective “liability operator” (or “sin eater“) for AI tools the same way that a subspecialized neuroradiologist could be. We’ve already seen in early trials that susceptibility to AI mistakes is experience-mediated.

So it does depend on how that dance plays out and how regulation plays a role in the implementation of AI tools going forward. There are several plausible outcomes (not to mention midlevel involvement if we can’t get our act together).

But, in the meantime, the willingness to do full-spectrum radiology is and will remain a desirable and valuable skill.

Since we are in a new academic year at the height of job time, I thought I’d post an update on the “demand for radiology subspecialties” from Independent Radiology, which currently features 152 private practices (an interesting nationwide slice of the radiology job market).

Here is the breakdown of subspecialty openings today:

• Body: 76% (115), previously 78%
• Mammo: 74% (113), previously 79%
• General: 68% (103), previously 71%
• Neuro: 63% (95), previously 66%
• MSK: 55% (84), previously 54%
• VIR: 43% (66), previously 43%
• Chest/Cardiovascular: 35% (53), previously 37%
• NM/PET: 29% (45), previously 34%
• Peds: 21% (33), previously 26%
• Neuro IR: 5% (8), previously 6%

The raw numbers have gone up but the percentages are slightly down: this reflects that more groups joining this year have specific needs and are more discriminating in what their openings are.

Body has overtaken Mammo. This is a small change, probably noise. Part of this is also that Body is often a stand-in for “we have too much general radiology but want everyone to be fellowship trained.” I’d venture most general radiologists are comfortable in one or more subspecialities, but somewhat fewer subspecialists are comfortable with general radiology (e.g. people fleeing academic practices).

Overall, some fellowships are more in demand in a we-want-people-with-fellowships-and-don’t-care-which way, and some are more in demand with a greater available degree of subspecialization. Body and neuro are more commonly subspecialized than MSK and NM/PET, but of course, the full spectrum is available to every degree somewhere.

I would also point out that certain subspecialties, like peds and neuro IR, are just less common in private practice. The plethora of those jobs isn’t well captured here.

Off-hours positions remain similar and plentiful: 39% are hiring for swing shifts, and 34% are hiring overnight radiologists. I suspect that those swing shifts in particular reflect not just specific group needs but also an attempt to tap into the available remote workforce and meet market conditions. (Speaking of, my group has a remote partnership-eligible swing shift opening in our general/community division in addition to regular on-site/hybrid partnership positions across the board and remote body/general employee positions.)

Overall, a similar 65% of groups have remote positions of some variety, and 34% (previously 30%) are willing to hire contractors in some fashion. The latter could be noise or a small sign of the growing teleradiology gig economy.

How radiologists generate revenue is straightforward (you read cases), but how they are compensated varies based on the employment model, practice structure, payor contracts, stipends, etc etc etc.

Comparing opportunities is challenging. One way to attempt an apples-to-apples comparison is by summarizing a position into a single figure: $/RVU.

You take your total compensation, divide by RVUs, and voila. If you earned $300,000 and generated 10,000 RVUs, then you made about $30/RVU. Easy peasy (assuming your RVUs are accurate and you actually use the correct compensation number to account for benefits when applicable etc).

The math is straightforward, and it’s a helpful metric that I always include in my job talks.

But:

A lot of nuance hides behind that single number: casemix, case complexity, shift hours, evenings/weekends, procedures, benefits, IT and operational friction, vibes, etc. How many RVUs you generate is impacted by the kinds of work you’re doing per unit of time as well as how many hours and days you work overall. Despite the intention behind RVUs, not all RVUs are created equal.

For some contractor positions or those with strict productivity-compensation, $/RVU is logically the metric many people want to optimize for. Understandably so, and this is probably the fastest-growing segment of the workforce.

As always, Goodhart

But as Goodhart’s Law states: “When a measure becomes a target, it ceases to be a good measure.” I would argue that, at least for some radiologists and probably many graduating trainees, the question isn’t only—or perhaps shouldn’t be—just reduced down to a core metric of how much money did I make this hour? The deeper question is: am I doing this job in a way that makes me feel more human, good, honest, and interested?

If that question resonates with you, the problem with addressing it is that metrics are easy and comfortable. Optimizing for them feels right if we’re trying to be rational. Fluffy things may be important, but they feel easier to be wrong about. When we’re making decisions based on a regret minimization framework, I suspect many people feel they’ll experience less regret when optimizing for metrics that accurately reflect at least a portion of reality—rather than optimizing for metrics where they fear they may exercise misjudgment.

Choosing the best-paying job feels defensible and likely to reduce regret if it ends up sucking. Choosing a job for vibes or culture seems risky—because you’ll feel more likely to believe you made the wrong decision after the fact. Making the soft call doesn’t protect you from the pains of hindsight bias. Surely, the signs will have been there when you filter the past through your knowledge of the present.

The narrative fallacy is a fallacy for a reason: we simply aren’t that good at making predictions. Choosing where to work has inherent, unavoidable uncertainty—no matter how you make decisions.

Staying Comfortable

Then, once we’re working, we should also acknowledge the role of status quo bias, which—for this context—we can summarize as: we are comfortable with things as they are, even if we don’t like them, and even if we might like alternatives more. This is especially true when alternatives carry uncertainty, but it still applies when some improvements are essentially certain.

When we do entertain change, we often rely on an instigating factor or wake-up call to alert us to the possibility of choice. We are not good at counterfactual thinking. We are usually unable to view what our life would have looked like if we’d made different decisions, and we often fail to imagine what life could look like until something forces our hand to overcome this cognitive inertia: the resignation of our work sibling, the unfair treatment of a close friend, frustration with a bad mistake, an uncollegial interaction, or a rendezvous with a former colleague whose grass seems so much greener that your mind rattles trying to reconcile the different universes you seem to inhabit.

No job is perfect, and comparison is certainly the thief of joy. Ideally, we would like our jobs and not regret our choices. But we should also be comfortable with the reality of the sunk cost fallacy: time spent in the wrong career is time already spent. We don’t need to be shackled by previous choices or gambles that didn’t pay off.

It’s possible to make a “good” choice based on the available information and have it not work out. It’s possible to make a choice for the wrong reasons and still win. We should always strive to optimize our processes, but still acknowledge that our ultimate desire is the happy outcome of a fulfilling journey.

In the end, I guarantee someone out there is making more per RVU than you are. You can, at least in part, choose how that makes you feel.

$$$

The radiology gig economy is growing, and the desire for remote positions and continued consolidation is pushing the field further down the path of commodification.

Money matters. (Of course it does!)

That $/RVU number is highly variable across the country based on a lot of reasonable and sometimes less reasonable payor and supply/demand factors. High compensation can be from high $/RVU, lots of RVUs, or especially both. Good contracts and stipends can enable very high compensation, especially for highly “productive” radiologists on a productivity model.

The question for any radiologist is what are the costs (if any) for you to optimize for it, and, as a field, what are the long-term consequences to this increasingly nationwide job market and Uberification?

Not everything worth doing has a dollar sign attached to it.

Here is the updated collection of my posts on radiology setups/hardware, ergonomics, and productivity:

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1. The Best Radiology Setup/Workstation Equipment

Here’s what I have idiosyncratically landed on as a stable happy set-up that balances efficiency and comfort (and an editorial selection of those favored by others).

Life is too short to use what comes with your computer.

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2. How I Use the Contour Shuttle for Radiology

This post could have been titled: Why and How to Use an Offhand Device for Radiology, Or maybe even: How to Make the Most of All Those Extra Buttons on Your Gaming Mouse or Similar Device

More buttons! Better scrolling! Save your wrist! Feel like a PACS ninja!

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3. AutoHotkey for Radiology

AutoHotkey is powerful free software you can use to control your computer and generate simple (or complex) macros to automate tedious or repetitive tasks.

Achieve frictionless hands-free dictation (and more!)
If you need more scrolling help, consider Autoscrolling with Autohotkey.

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4. Making the Most of PowerScribe

PowerScribe is ubiquitous in radiology practices across the country, and it’s the only dictation software I use in my job. It has many flaws, but there are plenty of things we can do to make the most of it…Here are some tips for making PowerScribe (360) suck less.

Don’t be a passive victim of bad corporate software. Read more about (totally worth it) automatic template launching here.

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5. Radiology Toys (TL;DR)

For the use-with-your-hands part, here are some quick contexts and a single choice for each that you can implement wherever you work:

Quick highlights: Optimizing is a worthy investment of time/energy/money.

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6. Using the Zelotes C18 for Radiology

The Zelotes is the cheapest vertical mouse that doesn’t suck, and it has enough buttons that it’s useful for everyday PACS functionality no matter where you work.

How to think about mice for radiology with a special focus on a very inexpensive “vertical mouse” (along with some alternatives).

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Feel free to bookmark this post, because I’ll also add any follow-ups here.

This isn’t earth-shattering stuff, but I do think it’s a tidy illustration of how a small, easy-to-make change with a relatively minimal amount of hassle can nonetheless reap a small but measurable benefit—and in the long term, meaningful time and energy savings.

I appreciate/hope that this will all be irrelevant for radiologists very soon, but while thousands of us are still using Powerscribe, this is still part of our worklife.
Read More →

A few weeks ago, I got to enjoy a pitch for another poorly conceived “revolutionary” radiology AI workflow and reporting tool.

Tech people: Just bring on a radiologist CMO and a couple more to work on product. Stop cheaping out. Give them stock if you can’t pay, but these mostly suck and will continue to suck.

Everyone is happy to have some radiologists as “partners” that are just customers beta testing your buggy, half-baked products for free, but not enough are using content experts to make useful software from the get-go using first principles rooted in real-world experience and expertise. I would also love to see less focus on peddling trash and more on building product.

Free advice: Maybe just build something straightforward using current capabilities that is easy to deploy integrate into current workflows that people want right now. Something that doesn’t require massive buy-in and changing your whole tech stack.

Enterprise software sucks. Build up some good will, go from there. Not everyone needs to raise a ton of money to milk the bubble of me-too “AI for X” wrappers. Make something that solves a small, specific, real pain point and enjoy a nice cash-flowing business for a few years.

Reinvest in the next product if you want—or don’t. Forget about multiple rounds of raising capital trying to build and scale a behemoth on a foundation of sand.

Now, if you really want to revolutionize everything and replace radiologists with magical AI powers, great, that’s totally fine. You may be able to skip lots of radiologist feedback (though I imagine you’d still be better off with some deeply integrated, thoughtful radiologists). Someone somewhere can revolutionize everything from farm to table, but there’s also low-hanging fruit to optimize specific parts of the workflow in the meantime. Every part of the imaging pipeline has tedious, essentially broken software tasks and inefficiencies, and in many situations, it’ll be easier to optimize them individually in the short term than try to replace everything wholesale.

In other news, if you’re a current software vendor, now is the time to improve your offerings before it’s too late.

Everyone is happy to play the enterprise software game and court big hospital systems. But no one wants to build a grassroots business working with real people doing real work—because it doesn’t scale easily and it’s hard to raise money for.

I know that getting customers is hard—but that may be because your product sucks, because of the friction involved in transitioning to an unproven solution, or because you can’t demonstrate real benefits beyond just saying “AI.”

Yes, inertia is real: your new thing needs to be way better than the incumbent or something you can plug in for a reasonable additional cost. That still leaves a lot of opportunity on the table.