In their newest best practice guidelines in the Annals of Internal Medicine, the American College of Physicians practically begs clinicians to stop chasing phantom pulmonary emboli. Nothing super new here, but they do explicitly call out the big offenders:

Best Practice Advice 1: Clinicians should use validated clinical prediction rules to estimate pretest probability in patients in whom acute PE is being considered.

Best Practice Advice 2: Clinicians should not obtain d-dimer measurements or imaging studies in patients with a low pretest probability of PE and who meet all Pulmonary Embolism Rule-Out Criteria.

Best Practice Advice 3: […] Clinicians should not use imaging studies as the initial test in patients who have a low or intermediate pretest probability of PE.

When I cover the ER, I am routinely impressed in the low diagnostic yield of a PE CT (for actual PE). When I review the chart in protocoling/interpreting these studies, it’s obvious that a significant portion of these patients are being imaged inappropriately, either because there is already a better diagnostic explanation from the initial history/workup, PE is clinically extremely unlikely, or because a positive d-dimer is being chased out of context. Until recently, this profligate waste was a winner to all involved parties.

• The ordering clinician could feel their anxiety and liability washed away.
• The patients could feel that they were getting a complete and thorough workup and were relieved when their tests were negative.1Don’t discount patient satisfaction and demand as important components of this trend, especially given the superimposed fear of a litigation in the event of a rare miss.
• The radiologist and hospital got paid.

Nagging concerns of radiation and systemic waste aside, everybody wins. And over time, the d-dimer turned into a bludgeon against reason, and the ready availability of CT made it psychologically and medicolegally more sensible to image aggressively.

The d-dimer was never intended as a screening test for every single patient with chest pain in the emergency room. A positive dimer in an inappropriately risk-stratified patient should not mandate a follow-up CTA. This is especially the case when the test is originally ordered by a nurse as part of a standing order protocol and not by physician who is actually responsible for the patient’s ultimate care. In my brief two-month stint doing clinical medicine in the ER as an intern, I often absorbed patients from the waiting room who already had an EKG, chest radiograph, and labs including troponins and a dimer. Then we were “forced” to get a PE protocol CT to “work-up” the dimer, even in patients who had obvious other explanations for the test results (e.g. an obvious pneumonia on the radiograph). Not everyone practices this way, but it’s easier to practice thoroughly (defensively) in most of the same ways it’s easier to give antibiotics for viral illnesses.

There is one important and misleading exception to premise of the ACP report. And that’s the notion that CTs ordered in the context of “suspected” PE are exclusively obtained to evaluate for PE (i.e. PE CTAs don’t have diagnostic value outside of evaluating for PE). Some of these patients have clinical symptoms without radiographic findings, and the ordering providers are obtaining imaging to further evaluate the lung parenchyma for signs of occult infection (as well a rib fractures, anything else). CT is a troubleshooting modality in cases where the clinical picture is cloudy. So the angiographic component of the CTA may be partially a “why-not” inclusion to exclude a potentially life threatening PE in a patient that was destined for imaging anyway.

That said, I still feel like I almost diagnose more PE incidentally on abdominal imaging than I do on dedicated PE studies.

Disclaimer: I was a resident who had neither started nor completed the process of getting a job when I wrote this. I was however asked to weigh in on pursuing a radiology job in academics vs. private practice, particularly with regards to how one’s future desires might shape an applicant’s choice of residency program. Overall, I still agree with myself.

There are several considerations to take into account when deciding the merits of a career in private practice versus academics. These are of course broad generalizations, and exceptions are not uncommon.

Variety

How much do you like variety versus how much you like the idea of being a hyperspecialized subspecialty radiologist?

Most academic radiologists work exclusively within the realm of their fellowship training. That means that even a single extra year of neuroradiology training will often lead to an academic career in which you essentially exclusively read neuroimaging (with maybe some general call thrown in at some institutions). As a resident, you will likely notice that some of your staff seem to know less about the “extraneous” anatomy and pathology than you do. That’s because at this point, years after they’ve practiced general radiology, that’s often true. It’s not uncommon for body staff to defer to the resident’s interpretation of spine findings on a belly CT or vice versa. Procedures you do, if any, will typically be those related to your subfield. Case complexity is higher overall and intra-system follow-up is more common. As such, the clinical work may be more satisfying as well as more narrow.

Private practice radiology is focused on interpreting studies. In general, subspecialty trained radiologists will still often perform as generalists even if they have a relative focus on their subfield. Even interventional radiologists, who some might assume would be fully clinically oriented, often only spend, say, 40-60% of their time doing IR. It’s become common for the subspecialist to be responsible for the highest level cases, but it’s still generally much less common to have an academic style laser-focused job in PP compared with academics. Case in point: a recent study showed that while almost 50% of current IR job postings were 100% IR, only 15% of PP jobs currently offered 100% IR.

So the go-to guy for pediatrics or musculoskeletal imaging still isn’t exclusively reading those studies. In small to mid-size groups, non-IR radiologists routinely perform many of the procedures you think of when you think of IR (biopsies, drainages, etc). A future exception: over time as more corporate mega-groups take over hospital contracts, the clinical volume can be largely pooled, allowing even the PP subspecialist to focus more on the subfield of their expertise. Given the continued push for “quality” and “value,” particularly as referrers become more comfortable with imaging themselves, this trend will also increase.

Conversely, an academician may pair their narrow clinical focus with a greater amount of nonclinical work. While the private practice radiologist may read a larger variety of studies, the academic radiologist is more likely to be involved in research, administration, or teaching. Both research-track and clinical-track jobs exist (though tenure as such is uncommon). In the end, you have to decide if radiology/study variety or career variety is more important. Again, at the risk of beating a dead horse, these are generalizations. There are people in academics who exist only to “kill the list,” and there are people out in practice who are involved in running practice groups, working with hospital administration, and spending a great deal of time during non-clinical work.

Money, Time, & The Future

Money is slowly becoming less of a factor for many than it used to be. During the golden age, you worked twice as hard in private practice and made three times more. Now maybe you’re working 50% harder for 20% more. Before reimbursement cuts, it wasn’t uncommon for people to make a lot of cash in PP and then “retire” into a slower-paced academic job (obviously this was also before the job market contraction). Those days are long gone and are never coming back. Groups are merging, and these consolidated megagroups are then snatching up the hospital contracts in large metro areas. Partnership track positions are no longer universal, and even when present, may not always be as meaningful, particularly in private equity-owned groups where it really just signifies a pay increase or smaller groups that don’t have long-term imaging contracts or don’t own imaging centers (and thus have no assets to bargain with except limited intellectual manpower). Hospitals are increasingly directly employing radiologists, and an employee is never paid what they’re worth (otherwise how does the employer profit from them!). This is to say that while you certainly make more in PP, that money doesn’t come for free, and the windfall isn’t as egregious as it used to be. It’s frequently described as a grind.

There are also some unsavory practices that churn and burn new grads out of fellowship, often for “partner-track” jobs where the associate is let go prior to making partner. Likewise, folks in the workup typically make out poorly in a group buy-out situation. This is a result of the desire to maintain or increase revenue amidst falling reimbursement, particularly for established partners who are used to bringing home a certain income. A private equity practice, for example, makes its money when old well-paid partners retire and are replaced by a younger less well-paid generation. As older radiologists retire, it’s possible the nature of these groups may change. That said, many young physicians would rather sacrifice some income for lifestyle. People talk. Make sure you know the nature of the group you sign on with.

Conversely, academics definitely isn’t as easy as it used to be. Changing reimbursement combined with ever-increasing clinical volume has resulted in a push for ever greater RVU generation, even in academics. This has meant an increasingly frenetic pace, particularly for those who are not producing academically enough to get protected time. While pay is generally lower, academic institutions often have great benefits. So salary itself isn’t the only consideration when it comes to true compensation.

So both groups are working harder than they used to. In PP, the grind is generally bigger and you take more call in return for lots more vacation and more money. How much more money depends on a lot on the health of the group, location, what patient population they service, assets they hold, etc. PP radiology was well suited to the era of fee-for-service medicine. In a future of more capitated and “value”-based healthcare, there will be more contraction and consolidation, likely resulting in further erosion of the historical differences over time.

Integrated health systems like Kaiser directly employing radiologists make a lot of sense in the era of bundled payments. So while many people weigh their options between private practice or being employed by an academic institution, a third option of being employed by a non-academic hospital or health network may become increasingly common. Such a job is likely similar to a clinical-track academic job for a bit more pay (i.e. not a bad thing for physicians).

Previously thought undesirable, some VA jobs have emerged as highly desirable jobs with reasonably high pay, an occasional light academic component, and preservation of lifestyle.

Service

While the referring physician is important to all referral-based specialties, the ordering provider is much much more the client for a radiologist than the patient. Service in private practice radiology means making those providers happy. In many cases, that will include non-physicians like NPs and PA as well as chiropractors and other folks. Yes, you’ll spend a lot of time on the phone being nice to people who may be ordering asinine studies and pretending you want to talk to them. Part of the gig.

Academics varies more, but generally, the referrers don’t choose you; you’re just in the system. So the dynamics can be different. At my institution, we have a system that allows us to send important results by a recorded message via pager. Saves us a ton of time. Some orderings docs hate it; we love it. That’s a harder sell on the private side.

Security

In general, academic jobs are much more secure. In large competitive metro areas, even group contracts aren’t necessarily secure in the long run, which adds an additional layer of insecurity.

Your residency choice

So what does this mean for your choice of residency? Not very much. Any large academic center, which most people aspire to, will offer you the training you need for either job. You don’t need to know right now. And don’t read the above and think PP has a grim future where only suffering exists (because that’s not true). If people ask you, you can either say you’re not sure, want to get the best training possible, or that you’re most interested in academics (after all, who’s interviewing you?) There are two mild caveats:

1. Volume & Autonomy

Private practice jobs are speed and competency-based. Which means a new hire is prized for being able to work through a list of unread studies quickly without making mistakes. As such, the residencies that best “prepare” trainees for private practice are ones that have good clinical volume (most do) and independent call (a challenging luxury that’s rapidly fading). Many programs have done away with independent call due to demands from EM departments for rapid final reads, no patient-care altering addendums, etc. While on the face of it this is a good thing for patient care, it ultimately displaces responsibility and training. Every radiology resident will eventually have to be able to “make a call” on tough cases. Doing it in the context of independent call means that someone with more experience will eventually back you up and provide quality assurance. This allows you to grow in skill and confidence in a relatively safe environment. If you don’t have this, the end result is that you are never meaningfully responsible for patient care until you’re a fellow or an attending. As an attending, you don’t have the same backup luxury. I’m not convinced this is a good thing: it makes young attendings less trustworthy and often overly sensitive/nonspecific.

There are programs with minimal call.2In many of these, the fellows take all the general call, which sucks for the fellows! These are easy residencies (and at some really big names) but probably not the best clinical training. You can be an exceptionally smart person with great book knowledge and that will take you part of the way—but you can’t teach independence, and you can’t substitute volume. There are also programs that treat the overnight ER shift like a normal workday with attending readouts—which means you never have to make a real decision for yourself. Successfully taking independent call and covering a busy emergency department/hospital is both educational but also signifies to groups that you won’t be useless when you’re hired. Most groups know the kinds of residents a program typically produces, at least on the local/regional level.

So essentially, if you’re interested in private practice (and most residents will need to at least consider entering practice), you want to be at a program that provides the best clinical training. That means good volume (large institution with large geographic radius to draw patients from), good faculty (to teach you), and call (preferably independent). Personally, I think these are important criteria for any job in radiology, but certainly for landing a decent PP job in a crowded market.

2. Location

A large percentage of residents stay in the same metro area for their first job after completing residency. This is particularly true for private practice, where residents from your program are more of a known variable and there are local contacts who can vouch for you. Academic institutions obviously don’t hire all of their fellows, doubly so at many of the big fellowship factory programs. So while a nice pedigree may help you get a job in academia (potentially at a remote institution), you’re statistically more likely to find a private practice job locally (unless the local market is completely saturated). The more awesome and desirable the place you train, the harder it will be to find a job there. Conventional wisdom is that if you want to practice in a certain municipality, you’re well served by going to the best locoregional academic program. If you know you want to be in academics and want a big name job, then feel free to chase pedigree to your particular desires (just know that the actual training is unlikely to be better; that’s not what the name is for; the name is to open doors with people who have pedigree biases. And maybe for you to do more research). Obviously, fellowship is another chance to play this part of the game.

A couple of months back, JACR published an article with the self-evident conclusion that patients would prefer to hear the results of their radiology studies from their doctor (the ordering provider) instead of a radiologist. Duh! Who wants to hear they have cancer from a stranger who they may never see you again nor have any role in their future care?

Buried in that revelation is far more interesting and depressing data. While many patients don’t really understand the difference between ophthalmologists & optometrists and psychiatrists & psychologists, a substantial portion of patients essentially have no idea what a radiologist even is. The surveyed patients believed radiologists are techs who actually operate the machines and not physicians, and they comically underestimated the length of training:

While 88% of patients were confident they knew what a radiologist is and what one does, 79% thought they were technologists (misplaced confidence!). Only 56% knew radiologists are physicians, and even fewer, 31%, believed that radiologists perform image-guided procedures. On average, they believed that the speciality requires an average training of 6.8 years after high school. Respondents at community hospitals estimated even less time, 5.3 years, which would make radiologists second year medical students.

So even though I think it’s clear that patients would (and probably should) want to hear their results from the ordering physician, it’s even less surprising that they’d want the news that way if the alternative is to hear the results from a nonphysician who just finished their first year or medical school.