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Radiology

Out of the darkness

The New Physician October 2007
As a first-year medical student, Dr. Adam Talenfeld remembers overhearing one fourth-year tell another, “There are three things you can do on a daily basis as a doctor: You can hold clinic and talk with patients, you can diagnose disease, and you can treat and do procedures. In most specialties you’ll spend most of your time doing two of these, so you just have to pick which two you like best.” But Talenfeld ultimately discovered a specialty that, for him, offers a taste of all three.


Radiology is usually thought of as a diagnostic specialty, but advances in its fastest-growing practice area—interventional radiology—allow radiologists to treat disease through minimally invasive, image-guided surgery, which comes with a significant amount of patient contact.


“I really like radiology’s emphasis on diagnosis, and I like that by specializing in imaging, I continue to learn about every organ system and almost every other specialty,” says Talenfeld, now in his fifth year of residency at Mount Sinai Medical Center in New York City. “But radiology [also] offers many opportunities for image-guided procedures/therapy.” And with his eye on an interventional radiology practice, “I also look forward to performing problem-focused consults and post-intervention follow-up visits as part of an office-based practice, as would any other surgical or procedural specialist.”


The stereotype of the pale, solitary doctor reading endless stacks of films in a dark, windowless room has been shattered by radiology’s progressive technologies. The advent of PACS—picture archiving and communication systems—has made reading film quick and efficient; meanwhile, innovations in molecular imaging are enabling radiologists to go beyond visualizing anatomy toward perceiving molecular changes in the body. “It’s a very interesting field—challenging and intellectually stimulating; You continually have to keep up,” says Dr. Martha Mainiero, professor of diagnostic imaging and director of Brown Medical School’s radiology residency program.


It’s also one of the most diverse specialties. Almost all radiology residents subspecialize, concentrating perhaps on specific organ systems—cardio, gastrointestinal, genitourinary, neuro—or on body regions, like abdominal, breast, musculoskeletal, or head and neck. Others subspecialize in the types of patients they treat, like pediatric, women’s or emergency. Most become experts in more than one area.


That’s one reason Dr. Matt Davenport, a PGY-3 at the University of Michigan, was attracted to the specialty: “It offers the best opportunity to become a master in a particular field. One of the nicer things about radiology is that, although you are already a resident, you still have many options in front of you. For instance, you can select a heavily procedural fellowship—e.g., interventional radiology—or something less so—e.g., emergency radiology.” Davenport adds that “although the bulk of your time is spent interpreting diagnostic images, radiology is at its core a procedural specialty. From conducting biopsies to performing cerebral angiograms, radiologists have ample opportunity to be as much or as little involved [with patients] as they wish.”


Residency training in radiology takes five years, with a minimum of four spent in diagnostic radiology. A minimum of six months must be spent in nuclear radiology, and a full year must be spent doing clinical training in internal medicine, pediatrics, surgery, OB-Gyn, neurology, family practice, emergency medicine, or some combination of these. This clinical year will usually be the first postgraduate year. In their fellowship year, radiology residents can explore neuroradiology, nuclear radiology, pediatric radiology or vascular and interventional radiology. (Radiation oncology is treated as a specialty distinct from radiology, having its own five-year residency track.)


Radiologists tend to work in group practices, most of which have hospital and outpatient components, although some practices focus on one setting or the other. The lifestyle is considered desirable and well-compensated. “Radiologists are fortunate,” Mainiero says, “in that they can get a job anywhere they like. And it’s a pretty controlled lifestyle, with some weekend or night call, but since it’s usually shared among a group practice, it’s not so burdensome.”


Radiologists can also adjust their schedule freely. “You have the capacity to work part time, or to work different shifts,” she adds. “Some people I know hire themselves out to do night call for other groups.”


But earning extra cash isn’t typically a problem for established practitioners; radiology is among the highest-paid medical careers. According to the American Medical Group Association’s 2006 compensation survey, those
performing interventional radiology earned a median salary of $424,992—an increase of 3.59 over 2005 and the sixth highest among the 108 specialties included in the survey. Noninterventional diagnostic radiologists ranked eighth overall, with a median of $400,000—an increase of 9.62 percent over the previous year.


But can the gravy train keep chugging? Medical students worry that the field is too competitive, and the growing use of nonphysician clinicians (NPCs) and “super technologists” to do imaging will further erode job availability. But Mainiero is reassuring: “The field has actually been projecting a shortage for a few years, so jobs are plentiful and easy to get.” And although training slots are necessarily limited by Medicaid funding and hospital staffing constraints—the 2007 Match filled all 141 PGY-1 slots in diagnostic radiology and 98 percent of the 902 PGY-2 slots—she notes that the number of positions offered has stayed stable or climbed slightly in recent years.


“The Match is competitive, but there are so many different kinds of programs, most people can usually find a fit. You don’t have to be at the top of your class,” says Mainiero.


As for NPCs, she reports, “Radiologists are starting to use physician assistants and X-ray techs to perform some of the procedures, but at this point there is so much to be done, [NPCs] are seen not as a threat but as an advantage. More imaging is being done, with more applications, and it has become central to the practice of medicine.”


Indeed, Davenport is stimulated by the number and range of cases he sees: “Every complicated patient makes his or her way down to the department at least once, if not a few dozen times,” he notes. “Every specialty uses our services and every specialty in some way or another relies on our advice. Therefore, as a radiologist, you are in a position to make significant alterations in the course of clinical care across nearly every medical specialty.”


The exciting pace of change and the multiplicity of patients may be one reason radiologists tend to stay in their jobs longer than most physicians. A study in the December 2006 issue of the American Journal of Roentgenology reported that more than half of practitioners over age 65 are still active in the field.


But no one seems to know exactly why the field remains so male-dominated. The latest study on gender gaps from the Radiological Society of North America failed to yield “a conclusive answer” as to why women, who make up almost half of all medical students, represent only one-quarter of diagnostic radiology residents.


“Women are much underrepresented in radiology,” Mainiero acknowledges. “We would like to see that change.” Anecdotally, women usually give the reason that there is not enough patient contact, or it’s too technology-centered, she explains. “But the reality is that we need all kinds of radiologists—the computer-savvy engineer technophile, as well as those who are patient-oriented and barely got through physics in high school.”


The specialty should appeal to anyone “who loves the intensely cerebral diagnostic exercise of medicine,” says Davenport. “Each day is spent making literally hundreds of decisions regarding benign and pathologic processes. You have the opportunity to know and be familiar with all the rarest diseases that you never thought you’d have to memorize—and even get to learn hundreds more you never knew existed! Not to mention the fact that radiology has become the hub of the hospital framework.”
Martha J. Frase is editor of The New Physician.