What Makes a Radiologist Feel Special?

Not all radiology jobs are created equal in part because not all radiologists with the same job are treated equally. In a field divided between democratic groups, corporate employers, and academic institutions, the meaning of fairness and the value of “specialness” vary wildly.

Compensation, autonomy, and respect are all on the table.

For different kinds of radiology jobs, there are different kinds of radiologists.

The Democratic “Ideal”

One thing about any traditional private practice is that, in most cases, all partners are equal. They share in the work and share in the profits. Typically, any differences in compensation—if there are any—are a reflection of differing schedules (like buying and selling of weekend call shifts or vacation) or a reflection of a productivity incentive component, where the radiologist earns additional income for RVUs generated in excess of some predetermined benchmark (because while pay is often equal, production often is not). An external entity can help support necessary admin time through stipends/directorships, but this usually comes from outside of the practice.

If things aren’t fair and transparent, something is wrong.

When Someone Else Holds the Keys

Radiologists working for a third party—like a PE-owned entity or a hospital/university medical center—are in a different situation.

Obviously, in some cases, people can be paid and valued similarly. But a third party holding the keys creates more opportunity for sweetheart deals and special treatment.

This isn’t a knock on those models, because ultimately while flexibility can be used poorly—by undervaluing people, rewarding friends, or exploting those who don’t negotiate—it can also be a powerful business tool (for “good”?) in the sense that you can flexibly pay what the market demands for a given in-demand skill set, even if it doesn’t seem “fair.”

If you’re trying to grow a service line (or keep one on life support) and you need someone with specific skills, you can choose to invest in that person in a way that can be challenging, if not impossible, in a democratic group.

In a world where some radiologists are attempting to optimize for $/RVU, we shouldn’t pretend that democracy always works or that “fairness” always feels fair.

In my practice, a 20-year veteran doesn’t make more for the same work as a new partner. In the academic center I trained at, some senior physicians earned more while doing less.

Now, for those special radiologists who are in demand (like breast imagers in recent years), the current shortage has again enabled a lot of offers—sometimes with high compensation or cush schedules available even for remote work—for the right kind of person for the right kind of job.

What may feel arbitrary or unfair may just be a necessary, intentional response to market forces in order to avoid operational insolvency.

Merit & Loyalty

There is also an important distinction between loyalty to an institution or a platonic ideal, loyalty to a deserving person, or nepotism. The classic academic notion of paying your dues and enjoying better pay with more respect and a better schedule merely through seniority is perhaps not the best way to create a well-functioning meritocratic enterprise.

Academic radiologists need to believe in both the mission and the institution to invest over the long term. Rapid turnover, bad governance, and obvious disparities can easily sabotage what should be the strongest cultures in healthcare.

I once knew an outstanding attending who left their institution because the new junior faculty (including some she helped train) were getting a better deal, including higher compensation. The market had moved, but the institution wasn’t willing to revisit established faculty salaries. The department isn’t a democracy, but this radiologist was worth more by all metrics.

If the academy can’t figure out how to balance specialness with fairness, it’s going to continue to exist in a no-man’s land between democratic private practice and commodified but well-paying corporate work. Many doctors have figured out that the institution often doesn’t love you back.

Rational Actors, Systemic Consequences?

What is best for the individual in the short term may be at odds with what is best for the community in the short term and/or the field in the long term.

This is just another reflection of the tragedy of the radiology commons that plagues all sectors of healthcare:

Those individual choices are logical. The “right” move having downstream effects doesn’t make it a bad choice, especially if the negative consequences are hypothetical or only occur if others pile on (and even then over a long time horizon); that’s why it’s called a tragedy: it’s mostly reasonable people doing reasonable things. Whether those individuals will find that their new opportunities are worth it—or live up to the anticipation—is, of course, unknowable.

Assuredly, sometimes they do. The radiology gig economy is growing precisely because there are a lot of people optimizing for compensation-per-effort and/or flexibility, and some are clearly very satisfied.

But, sometimes, the reality doesn’t quite live up to the expectation. Certainly, some groups that sold to RP over the past decade have regretted the decision. And I see no reason to assume that trends toward commodified pay-per-widget work in a consolidated world will lead to maximum radiologist utility over a long-term time horizon.

Rates per RVU are awesome—but only when they’re high. In the long run, commodification doesn’t care how special you used to be.