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.

I believe in the importance of thriving independent private practices for the field of radiology. True private practice—where doctors control the organization, are responsible to their peers and patients, and earn the full fruits of their labor—is the benchmark that sets the market and provides the anchor against exploitation from unscrupulous employers.

My group, like most groups in this market, is hiring. Here are several more 100%-independent radiologist-owned private practices across the US that are recruiting. If you’re in the market for a new position, consider reaching out with your CV. (Click the triangles for more information.)

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Radiology and Imaging Specialists

(Central Florida: Lakeland/Winter Haven, SW Orlando, Bradenton)

Independent and long-standing group covering a diverse mix of financially sound hospital partners, outpatient imaging centers, an ASC/OBL, clinics, and a multi-specialty group. 50+ radiologists and 10+ midlevel providers. In-house and experienced IT, Credentialing, HR, and Admin team including dedicated Radiology Liaison support 24/7/365.

Recruiting for Body, Breast, Cardiac, Neuro, IR, and General.

Partnership Track:

• 1-year track for diagnostic radiologists, 2-year track for interventional radiologists
• 10 weeks of vacation
• Sign-on bonus for diagnostic radiologists
• Call compensation for interventional radiologists
• Internal moonlighting available but not required
• Full benefits including CME allocation

Employee or Contractor:

• Flexible scheduling: Hospital (ED/IP) or outpatient coverage options available
• Fully remote, hybrid, or on-site depending on location(s) and coverage schedule desired
• Competitive compensation models (including benefits if employed/full-time)

Learn more at http://risimaging.com.
Contact: Alice Varnadore, Executive Assistant at avarnadore@risimaging.com

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South Texas Radiology Group

(San Antonio, Texas)

STRG is a well-established, expanding, independent subspecialty practice of 70+ radiologists serving 15 hospitals, multiple freestanding ED facilities, and a large outpatient imaging practice (STRIC). Both onsite and remote positions are available.

STRG is a forward-thinking practice with a strong and cohesive culture. Multiple AI projects are in place and in progress to improve efficiency and quality. Internal moonlighting opportunities are available.

Shareholder Track:

• Flexible associate period as short as 18-months.
• Leads to full partnership with board of directors membership.
• Equity ownership within a large expanding outpatient imaging practice (STRIC)
• Competitive salary with up to $800K starting salary for experienced applicants. Up to $600K starting salary for inexperienced applicants.
• Excellent benefits package
• Onsite and work-from-home options for daily work and call
• Hiring across all specialties, with a current emphasis on Body Imaging and Cardiothoracic/Body

Emergency Radiology Track:

• 1 week on/1 week off (7/7) and 1 week on/2 weeks off (7/14) positions available
• Competitive salary with excellent benefits package available.
• Fully remote and onsite options available.

Employee Mammography Position (Onsite):

• Competitive base salary with excellent benefits package
• No call. No nights or weekends.
• Remote opportunities available for general radiology or body imaging work if interested.

Employee Position – All Subspecialties (Onsite, Hybrid, or Remote ):

• Competitive base salary with excellent benefits package
• 5.5 weekends (day shift) per year. No evening or overnight call.

Learn more at https://stric.com/.
Contact: Waynea Finley at wfinley@strg-pa.com

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Radiology of Huntsville

(Huntsville, Alabama)

ROH is 60+ physician, high volume, private practice with a 2-year partnership track and nominal buy-in. Hiring for a remote partnership-eligible overnight position as well as onsite/remote openings in most subspecialites. Huntsville is a tremendously livable, high-tech, and growing mid-sized city (a #1 Best Place to Live in the U.S. by U.S. News and World Report).

Learn more at www.radiologyofhuntsville.com.
Contact: Brandy McCown at bmccown@radhunt.com or call 256.713.0621.

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Iowa Radiology

(Des Moines, Iowa)

34-radiologist subspecialized collegial private practice with long-term stability providing coverage to 30 locations across Central and North Central Iowa. Ownership of several outpatient imaging locations yields distributions from technical fees, and Des Moines is one of the fastest-growing areas in the country with a low cost of living, excellent schools, and low taxes.

Partnership track:

• 2-year partnership track with 12 weeks vacation
• On-site daytime coverage; hybrid night and weekend call coverage
• Greatest needs: Breast, Neuro, General. All subspecialties considered for the right candidate.

Employee track:

• Fully remote, hybrid, or on-site options
• Excellent salary and benefits package, including up to 10 weeks of vacation depending on role/shift
• Immediate Need: 3^rd Shift Radiologist
  • Nine-hour shift, 7 on/14 off, 100% teleradiology
  • 90-120 cases/shift; ~40 of those CT
  • Base compensation $450,000 w/ additional compensation opportunities
    • Additional comp consideration based on subspecialty (for example, can final read neuro cases)
    • Moonlighting available
    • RVU productivity incentives
  • Full benefits package including 401k, health/dental/vision, pension, life insurance, etc. ($83k benefit value annually)
  • Malpractice and tail paid
• Other Available positions: General, Breast, Flex Shift, Overnight
  • Overnight shift is 10p-8a CST, 7 on/14 off, 100% teleradiology with average 90-120 total cases per shift
  • Evening shift is 4p-12a CST, alternating weeks M-F only (26 weeks and no holidays/weekends)

Learn more at http://www.iowaradiology.com
Contact: recruit@iowarad.com

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Mecklenburg Radiology Associates

(Charlotte, North Carolina)

Established in 1917 and fiercely independent, MRA is a well-respected subspecialized practice of 60 radiologists and growing. They especially take pride in their group culture (seriously, there are some really nice people in that group including one of my old senior residents).

Partnership track:

• 3-year partnership track with 8 weeks of vacation per year
  $400K starting salary and an additional $75K sign-on bonus ($125K with 2+ years of experience)
• On-site daytime hospital and imaging center coverage. Hybrid evening and weekend call coverage, including the option to read from home.
• Available positions: Breast, Body, Cardiovascular, Neuro, Light IR, MSK, Nuclear Medicine, and General

Employee track:

• Fully remote, hybrid, or on-site options
• Competitive salary
• Available positions: MSK, General, Overnight ER, Swing Shift ER, Neuro, Body, and Cardiovascular

Learn more at www.meckrad.com/recruitment.
Contact: Charlene Eichinger at ceichinger@meckrad.com

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Midwest Radiology

(Minneapolis – St. Paul, Minnesota)

Large 175+ subspecialized practice with 17 weeks of vacation. Two-year shareholder track for new graduates and a one-year track with experience.

Positions (On-site):

Positions (Remote):

Learn more at www.midwestradiology.com.
Contact: Barry.Lindo@MidwestRadiology.com

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RAPA

(Central Arkansas [Little Rock, Conway, Searcy, and Pine Bluff] & Northwest Arkansas)

40+ radiologists covering 20+ sites (hospitals + clinics) with a multi-subspecialty mix of inpatient, outpatient, and ED imaging.

• Robust reading room assistants and IT presence to promote peak efficiency
• Unified Clario reading list, Inteleviewer PACS, Powerscribe dictation (no switching stations or PACS to read other sites)
• RadAI automated impressions to improve efficiency.

Partnership track – Central Arkansas (Little Rock, Conway, Searcy, and Pine Bluff) and Northwest Arkansas:

• 1 year to partnership
• 10 weeks vacation + 1/2 day off per week on average for partners
• Highly competitive compensation combined with low cost of living
• Internal moonlighting options to boost income
• Robust CME allowance, signing and moving bonuses, full benefits
• Many work-from-home shift options
• Minimal after-hours requirements – overnight shifts are fully staffed with telerads

100% Remote Nighthawk, partnership track:

• 7 on/14 off, 10 pm-7:45 am CST
• 1 year to partnership
• Competitive compensation, robust CME allowance, signing bonus, full benefits

100% Remote Neuro/General:

• Daytime tele neuro/general radiology approximately 50/50 split.
• Option for employed or partner track. Partner track includes call weekend shifts, approximately 1 in 5 weekends.

Employee track:

• General radiology, mammography, and other options available
• Fully remote, hybrid, or on-site options available
• Flexible scheduling
• Competitive salaries
• Robust CME allowance, signing and moving bonuses, full benefits

Greatest needs are IR, mammography, body imaging, MSK, and nuclear medicine, but all subspecialties and general radiologists are welcome.

Learn more at http://rapaxray.com/
Contact: recruitment@rapaxray.com and Dr. Brandon Kelly at bkelly@rapaxray.com

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Eastern Radiologists

(Greenville & Coastal North Carolina)

Eastern Radiologists is a private practice in Eastern North Carolina that is physician-owned and operated and seeking to hire multiple radiologists due to growth and retirement. The well-established private practice serves a large geographic region through 14 area hospitals and several state-of-the-art imaging centers. Support is provided by nearly 70 subspecialty radiologists.

Currently seeking candidates with the following training:

• Pediatric Imaging
• Breast Imaging
• Neuroradiology
• Body Imaging
• Nighthawk/Overnight
• General Diagnostic Radiology
• Vascular/Interventional

Details:

• Positions are available in Greenville and other coastal communities in Eastern North Carolina.
• Most are partnership track positions which include evening and weekend call responsibilities, but other employment options can be considered. Employment positions can be customized to fit desired schedule/income. Internal moonlighting is available for extra income.
• Great benefits, competitive salary including profit sharing and bonus, generous vacation and paid family leave, and business/educational discretionary account.
• Sign-on bonus

Learn more at https://www.easternrad.com.
Contact: Erica Askew at easkew@easternrad.com

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Reno Radiological Associates

(Reno, Nevada)

Serving Northern Nevada since 1947, RRA is a strong, highly subspecialized, democratic, extremely collegial, high-earning group of 25 radiologists working in perhaps the best city in the country for raising a family and enjoying unparalleled access to natural beauty, endless outdoor activities (perhaps the best ski-city in the US), and incredible weather (jokingly referred to as “the cheapest city in California” for its proximity to Lake Tahoe (<30 min), Napa Valley, national parks, and more without the super high cost of living and no state income tax).

Shareholder Track (onsite):

• 1 year to 75% partner, 2 years to 100%
• Top 90+% comp nationally, maximally generous benefits
• 8/9/10+ weeks of vacation
• Remote shifts + opportunities for extra income, $100 buy-in

Employee Track (remote or onsite):

• High comp, Maximally generous benefits, opportunities for extra income
• Flexible fully remote options (11a-8p, 8p-3a, or 3a-11a PST)

Independent Contractor (remote or onsite):

• Flexible shift options (as above), high compensation

Learn more at http://www.renorad.com/
Contact: CEO Anthony Dispenziere at adispenziere@renorad.com

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Vantage Radiology & Diagnostic Services

(Near Seattle, Washington)

~35 subspecialized radiologists practicing near Seattle and enjoying a quality lifestyle focused on work-life balance, located minutes from urban amenities, and with easy access to abundant outdoor activities in the natural beauty of the Pacific Northwest. We’ve provided professional services for two hospitals since 1970 and are co-owners of their affiliated imaging centers.

• Competitive salary ($370-570k) with a signing bonus for a 4-day work week and 8 weeks of vacation.
• Benefits include a CME allowance, memberships to professional societies, profit-sharing, malpractice and disability insurance, 401K contributions, and a commitment to associate mentorship.
• All partners and partner-track associates share in general call responsibilities (many from a practice-provided remote home workstation). Overnight call is covered by our internal nighthawk team.

Openings:

Learn more at https://www.vrads.com/
Contact: recruiting@vrads.com

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Radiology Consultants of Little Rock

(Little Rock, Arkansas)

Founded in 1961, RCLR is a 25+ radiologist, subspecialized, independent private practice serving the largest healthcare system in Arkansas as well as the largest urology group in the state.

Early Evening/Swing Position:

• Fully remote
• 7 on/7 off but with the perk of being excused from 6 weekends per year
  • Excused from holidays that may fall on your scheduled week but share in overall holiday coverage evenly with the rest of the partnership
• 8-hour shifts, 12 – 8 PM central time
  • Ideal for radiologists in the Pacific time zone
• ~80 RVUs/shift average
• All modalities excluding breast and PET, NM is minimal
• Starting salary of $575K for experienced candidates
• 1-year track to full partnership
• Competitive partner salary
• Internal moonlighting optional
• Benefits: 401(k), health/dental/vision, life and disability insurance
• Single IT stack

Learn more at https://www.radconlr.com
Contact: Terrie Threlkeld at terrie.threlkeld@radconlr.com

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Grand Traverse Radiologists

(Traverse City, Michigan)

Established in 1938, GTR is a 100% physician-owned and operated private practice in a four-season resort town on the bays of Lake Michigan.

• High compensation and 12 weeks vacation
• Post-call weekend days off
• Internal moonlighting available
• Positions/partnerships are on-site, but multiple shifts can be done from home.
• Collegial and youthful group with an average age under 40. All partners are equal.
• Hiring for growth. Lists are caught up!

Needs: Body, Breast, ER/General, and IR

Learn more at https://www.grandtraverseradiologists.com
Contact: Dr. Anthony Livorine at alivorine@gtradiologists.com

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Inland Imaging

(Washington, Oregon, Montana)

Inland Imaging is a 120+ radiologist-owned private practice proudly serving multiple outpatient, clinic, and hospital sites throughout the Inland Northwest region. We own and operate one of the first outpatient interventional labs in the West in addition to 7 outpatient imaging centers.

Our practice:

• Sub-specialty interpretations available across all locations.
• All studies are accessible on a common PACS system, one common voice recognition system, and one common worklist
• Internal Nighthawk System providing final interpretations on all ER, STAT, and Inpatient Exams. 24/7 Neuroradiology Coverage and IR Call Coverage.
• 2-year Partnership Track.
• Full-Time Radiologist Average Time Off = 15 weeks with the ability to decrease or increase total time off.
• Average after-hours obligations = 9 weekends per year and 22 evening/swing Shifts.
• Salary Range – $450,000 – $600,000
• Full Benefit Package including health, life, vision, dental, disability, and life.
• 401k match, profit-sharing contribution, and cash balance plan.
• Hybrid Work Options

Current Openings:

• Remote overnight ER
• Neuroradiology (choice of Spokane, Seattle, Walla Walla, Tri-Cities, or Missoula)
• Washington
  • Tri-Cities (with $75k signing bonus)
    • Breast
    • Neuro
    • MSK
  • Spokane – Pediatrics
  • Moses Lake – General/Breast (with $90k signing bonus, $20k relocation benefit, and annual retention bonus)
  • Colville – General/Breast
• Montana
  • Missoula – IR
• Oregon
  • Pendleton – General/Breast

More information about these positions can be found on our Independent Radiology listing.

Learn more at https://inlandimaging.com/careers
Contact: Sarah Russell, CEO at srussell@inlandimaging.com

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If you’re a group looking to advertise, get in touch. The monthly post here is limited to just a handful of groups at a time, but last year, I launched Independent Radiology as a resource for the broader community, a dedicated private practice radiology job board featuring 150+ groups. If you’re in the market, please also check it out for your job-hunting needs.

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.

Time for my annual update and bump of this post: like every other practice in the country, my group is also hiring!

American Radiology Associates is a 100%-independent physician-owned radiology practice in Dallas-Forth Worth (of which I am a partner/shareholder). We’re privademic: we have part of the practice that works with the Baylor Dallas radiology residency, and we have part of the practice that does not. I’m the program director, and I still enjoy a nice mix. Just imagine the fun no-BS parts of teaching and variety without the rigid hierarchy and inflexibility.

We’re hiring for body, general, neuro, NM/PET, and breast. All of us in DFW work a hybrid on-site/remote schedule and the option of a 4-day workweek. We are also hiring teleradiologists for body/general imaging.

While our partners are generally in the Dallas/Fort Worth metroplex, we are also offering a 100%-remote partnership-eligible swing position.

The swing shift is 2 pm-10 pm Central Time, weekdays (M-F) alternating every other week + 13 weekends of call (yes that means mostly weekdays and not 7/7 (which is 26 weekends), and never any deep nights or super weird circadian-destroying hours). The shifts are a mixture of early outpatient and subsequent general (body + neuro) ED/inpatient work for our regional/community hospitals. Other schedule configurations could be considered on an employee or 1099 basis.

So if you’re in the market, come work with me and check out our great team in Dallas. If you’re interested, send your CV to careers@americanrad.com and CC me at ben.white@americanrad.com.

Read More →

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.