Radiology ties with orthopedic surgery as the top-paying medical specialty, with radiologists earning an average income of $315,000 a year, according to a 2012 Medscape survey. But no one should pursue radiology primarily for the pay, caution leaders in the field.
“Those who choose the specialty based on money will be disappointed,” says George E. Erbacher, DO, the immediate past president of the American Osteopathic College of Radiology (AOCR).
First, reimbursement for radiologists is declining as the U.S. health system shifts toward a payment model that emphasizes primary care. Between 2010 and 2011, radiologists’ compensation decreased by 10%, the Medscape survey notes.
Second, requiring many years of training, radiology is one of the most demanding specialties. Students match into a linked internship in their fourth year of medical school followed by a four-year diagnostic radiology residency. Most radiologists then complete one or more fellowships in such subspecialties as interventional radiology and pediatric radiology or in specific imaging processes and anatomical areas.
Interventional neuroradiologist Wade Wong, DO, for one, served three fellowships beyond his diagnostic radiology residency: two years of neuroradiology, two years of interventional radiology and one year of interventional pain management.
Third, radiologists put in long hours, so this is not the best specialty for those who seek work-life balance, despite the norm of six to eight weeks of paid vacation a year. Most diagnostic radiologists have a 10- or 12-hour work day, work some weekends and take call. Interventional radiologists work even more, says Dr. Wong, who has experienced many nights with little sleep during the course of his decades-long career.
“For many years, it wasn’t unusual for me to have a 12- to 14-hour day, then be on call and have to get up in the middle of the night for a patient who had a brain stroke,” points out the AOCR’s president-elect. “And often I’d be up the rest of the night and have to work a full day the next day.”
But radiology is richly satisfying for those who love to solve problems, make differential diagnoses, and advise other physicians on treatment options. And interventional radiologists, who have considerable contact with patients, are at the vanguard of using noninvasive procedures to combat cancer, life-threatening blood clots and other disease processes.
“We’re the doctor’s doctor,” says Dennis P. Vollman, DO, the director of the AOA-approved diagnostic radiology residency at Garden City (Mich.) Hospital. Constantly interacting with physicians of different specialties, writing report after report, radiologists need excellent oral and written communication skills. Even diagnostic radiologists spend time with patients when doing procedures, so interpersonal skills, compassion and empathy are important.
As for cognitive traits, individuals with a strong science background and top-notch analytical abilities tend to do better in radiology, Dr. Vollman says.
Radiology appeals to detail-minded individuals who like detective work, notes Dr. Wong. “You need a good understanding of anatomy and curiosity about what makes the body tick,” he says.
Visual acuity—the knack for finding the proverbial needle in a haystack—is crucial for radiologists, adds Rocky Saenz, DO, who directs the AOA-approved diagnostic radiology residency at Botsford Hospital in Farmington Hills, Mich.
For example, when magnetic resonance imaging (MRI) is used, a radiologist may look at more than 1,000 images of an anatomical area, of which only two show any abnormalities. “And those two images may have just one little spot on them that is abnormal,” Dr. Saenz says. Medical students who as kids could easily find the bespectacled namesake of the Where’s Waldo? books may have sharp enough eyes for this specialty, he says.
Diagnostic radiology is one of the most competitive specialties. With roughly 35 funded positions each year in 14 AOA-approved residency programs, the number of slots falls far short of demand. Most programs have dozens of applicants per position.
“On average, we get between 70 and 100 applications for one or two positions a year,” says Garden City Hospital’s Dr. Vollman. Botsford Hospital receives approximately 100 applications for its three annual radiology openings.
Slightly more than half of DO radiology candidates enter diagnostic radiology programs accredited by the Accreditation Council for Graduate Medical Education (ACGME), of which there are more than 180. Many of these programs are much more competitive than the AOA-approved programs. For example, the University of California San Diego Health System has as many as 1,500 applicants for eight radiology residency positions a year, says Dr. Wong, who is the system’s chief of neurointerventional spine radiology and previously served on its radiology resident selection committee.
To maximize their chances of matching into an AOA-approved or ACGME-accredited radiology residency, many osteopathic medical students take the United States Medical Licensing Examination as well as the Comprehensive Osteopathic Medical Licensing Examination (COMLEX)—USA. High board scores are a must for radiology applicants.
Osteopathic medical students who matched into diagnostic radiology as their first-choice specialty in 2011 had an average score of 574 on Level 1 of COMLEX-USA and 543 on Level 2-Cognitive Evaluation, while 100% passed Level 2-Performance Evaluation on the first attempt, according to Osteopathic GME Match Report—For the 2011 Match.
Garden City Hospital requires that all candidates for its radiology slots score at least 500 on COMLEX-USA Level 1 and be in the top half of their class, Dr. Vollman says. Applicants who make that cut receive points based on their scores, class rank, letters of recommendation, personal statement and community service.
“I consider community service important because I want to see that applicants are well-rounded people and team players,” Dr. Vollman explains. “Are they going to raise the boat of the residency, or are they going to be off on their own in a life raft?”
In 2011, 96% of radiology candidates who matched into AOA-approved programs had volunteer experience, with an average of six volunteer activities per candidate, according to the Osteopathic GME Match Report.
Research experience is important for students who hope to match into competitive ACGME-accredited radiology residencies such as the one at University of California San Diego Health System, Dr. Wong says.
But for AOA-approved diagnostic radiology programs, research experience holds less weight than volunteer experience. In 2011, 65% of applicants who successfully matched into osteopathic radiology programs had research experience. These candidates had two separate research experiences on average.
At Botsford Hospital, a panel of three attending radiologists vets the radiology residency applications. “I have one attending who spends all of his time on the personal statements,” Dr. Saenz says. “If a personal statement has a grammatical error, he will tell me not to invite the applicant for an interview, even if the applicant has high board scores and grades. Writing skills are important because of all the reports diagnostic radiologists write, and attention to detail is essential in all that we do.”
Besides standing out on paper, radiology residency candidates should do their best to become known to program directors of sought-after residencies. Ideally, students should serve an elective radiology rotation at the target institution.
Many osteopathic medical students serve two- or four-week radiology audition rotations at Botsford Hospital. Students make the best impression by showing exceptional enthusiasm, aptitude and work habits.
Dr. Saenz points out that only two osteopathic medical schools have required radiology classes—the Michigan State University College of Osteopathic Medicine in East Lansing and the University of North Texas Health Science Center/Texas College of Osteopathic Medicine in Fort Worth. Students from these schools have already read a radiology textbook and typically have an edge over others because of their head start. Students from other schools, however, can read a radiology text or two to prepare for their rotations and gauge their potential interest in the field.
As they spend a lot of time with residents, students on rotation need to try to fit in. Competitive, goal-oriented “gunners,” who show up early, work late and come across as know-it-alls, can alienate residents, Dr. Saenz says, noting that current residents often play a key role in the selection of new residents to a program.
“However, as a program director, I like gunners because they show initiative and a lot of interest in radiology,” he adds. Nevertheless, ambition should be balanced with likeability.
But even stellar performance and popularity during a rotation doesn’t ensure an interview. Ongoing initiative and persistence may be necessary.
“A number of years ago, a medical student from New York spent three months rotating with us in interventional radiology,” Dr. Wong remembers. “But when she submitted her residency application, she was not extended an interview. She didn’t make the initial cut.
“So she called the diagnostic radiology program director, who didn’t know her, and said, ‘There must be some mistake. I rotated in interventional radiology and was told I did an outstanding job.’ She then contacted the people she rotated with on the interventional side, and they spoke with the residency director and got her an interview. She ended up matching with us and was one of the best residents I’ve ever seen.”
Because of the competition for rotation slots, however, formally rotating with desired radiology programs isn’t always possible.
“Of the 20 candidates we interview, typically 10 or so have rotated through our program,” Dr. Saenz says. Those who can’t get a formal radiology rotation at an institution should still contact the program director, he suggests.
“I get emails all the time from students who say, ‘I want to rotate with you, but I can’t get a spot. What do I do?’ ” Dr. Saenz says. “Sometimes I ask these students to come by on their own time to talk with me and observe our program. And if they have another rotation at our hospital, they can spend time in radiology before or after their required rotation hours in that other specialty.”
Dr. Wong recommends that first- and second-year med students who think they might like radiology get exposure to the field early on. This may help them secure rotation spots and residencies later.
“If you have any inkling that you might want to do radiology, talk to a radiologist about the field and see if you can shadow him or her,” Dr. Wong advises. “Between my first and second year, I did a summer externship with a DO radiologist. That really firmed up my feelings about going into the specialty.”
Long gone are the days when radiologists simply sat in the hospital basement looking at images. With imaging often supplanting the physical examination as the main diagnostic tool and with the proliferation of new imaging technology, radiologists have risen dramatically in status.
“I talk to physicians of all types every day about their patients, suggesting that certain patients have biopsies, others have colonoscopies, and so forth,” says Dr. Saenz, who completed an MRI fellowship. “We help other physicians problem-solve.”
But radiology is not strictly a cognitive specialty. Though a diagnostic radiologist, Dr. Saenz spends about 25% of his time doing procedures on patients using needle-sized and other minuscule tools. Two procedures he and other diagnostic radiologists perform frequently are paracentesis to drain excess fluid from the abdominal cavity and thoracentesis to remove excess fluid and air from the lungs and chest wall. Another common procedure is catheter embolization to block blood vessels, often used to stop abnormal uterine bleeding from fibroid tumors.
Interventional radiologists, however, perform the most procedures. “We use image-guided tools to fix things,” Dr. Erbacher says. “Almost everything we do is through a 1/4-inch nick—an in-and-out day procedure that is less expensive and less invasive and less risky than surgical alternatives.”
The program director of a new AOA-approved interventional radiology fellowship at Oklahoma State University Medical Center in Tulsa, Dr. Erbacher favors candidates whom he knows. “Face time is super important,” he says. “How can you learn about somebody as a human being off a piece of paper or a CV?” Attractive fellowship candidates will have served an interventional radiology rotation at the medical center.
Do interventional radiologists, with their precision procedures, need exceptional fine motor skills and dexterity? “We’re looking for caring, compassionate, excellent clinical physicians,” says Dr. Erbacher. “Then we’ll take it from there.”