Life After Residency: Be Nice, Brush Up on Business, Go High-Tech

Over the past 20 years, not only has clinical instruction during radiology residency changed, but so has the practice life that comes after it. Even as a growing number of medical students select radiology as a specialty, practice-setting preferences have shifted for your younger colleagues. They also have a different set of priorities to consider.

Unlike generations past, most radiology residents don’t transition directly into practice. Almost all continue on to fellowship training, preparing themselves for sub-specialty practice. The extra training prepares young practitioners for clinical care, but it does little to get them ready for the realities and complexities of day-to-day practice.

“As an industry, radiology doesn’t do enough to prepare our residents,” said Keith Smith, MD, former director of the radiology residency program at the University of North Carolina at Chapel Hill School of Medicine. “Largely, residents are very focused on passing their board exams and have very little mental energy left for other things. We do talk about life in private practice and billing and documentation, however.”

And, from those conversations, he said, it’s appears that the majority of radiology residents are forgoing private practice for the security of an employment position with a hospital or larger physician practice.

Be Cordial and Cooperative

After residency, the first priority for new practitioners must be changing how their view relationships with referring physicians, Smith said. Residents often maintain an “us versus them” mentality, fostering contentious interactions.

“Many residents look at requests for service from other departments as additional burdens,” he said. “They react with dread when asked to do things when, once they’re out in practice, they begin to see it as a paycheck. Having a good working relationship with referring physicians and understanding their needs can be very helpful.”

Ben Huang, MD, a UNC radiologist who finished residency in 2005, said he once viewed requests from referring physicians as a waste of his time. As an attending today, however, he appreciates the need for collegiality between radiologists and other specialties.

“When I was a resident, I tended to be more obstructionist,” Huang said. “I let the attendings make the final calls, so it didn’t matter if I were diplomatic with the referring physicians.”
But cultivating relationships with referring physicians has been advantageous for him. Primary care providers and other physicians have gotten a clear sense of who he is as a radiologist over time and are comfortable sending their patients to him for diagnostic imaging services. This is increasingly more important as radiologists are becoming a more involved partner in patient care, advising on image appropriateness, a new role spurred by healthcare reform and patient safety initiatives.

Know Your Business

While new practitioners are well versed in reading studies and consulting with referring physicians about the best scans to conduct, they know very little about the financial aspects of being in practice, said Paul Kiproff, MD, chair of the West Penn Allegheny Health System radiology department.

“Radiologists often lack a basic understanding of the business management end of practice,” Kiproff said. “But it’s good for them to have a grasp of what it means to code for certain procedures, such as CT scans, so they know exactly what they must do to qualify for payment.”
Although most clinical care settings have staff devoted specifically to coding and billing, new providers should have at least a fundamental understanding of the reimbursement process. In a healthcare reform environment barreling toward accountable and coordinated care, your young colleagues will benefit from any knowledge that will help them control costs, Kiproff said.

Residents and new practitioners should also make it a standard practice to include as much detail as possible in the patient record. With a more complete file in hand, coders will be less likely to request clarifications, reducing interruptions to the flow of patient care.

Be Prepared For More Workload

Despite reading the same studies and working equally long shifts, residents don’t carry the same workload as attending physicians. According to UNC’s Huang, residents would benefit from having a greater awareness of how much heavier their responsibilities will be once they enter practice.

“Depending on the program, some residents read as few as 25 studies in a day, but that can triple or quadruple,” Huang said. “They might be able to take longer now to read studies, but it can be a rude awakening to realize they won’t be able to ponder over cases for 30 to 45 minutes once they’re in practice.”

It is possible for residents to get more hands-on experience, however. Third-year residents at West Penn Allegheny provide more independent patient care when they take on additional night float shifts. They still have attending back-up, Kiproff said, but they get a better sense of what it’s like offer services without a safety net.

Don’t Expect Your Dream Job

Radiology has weathered the current weak economy well, but the job market isn’t as wide open at it was two years ago, Kiproff said. Residents and fellows finishing their training shouldn’t expect to find the perfect job in the perfect location immediately. Instead, he said, if they are currently in a salaried position, they should consider remaining there until the economy begins to rebound.

From a practical perspective, UNC’s Smith said he cautions his residents not to buy expensive houses or cars after accepting their first job offer. However tempting it may be, that position isn’t likely to be their last, and they might regret becoming tied to a location too quickly.
Instructing residents to think beyond honing their interpretive skills could also help them. Speaking at this year’s RSNA meeting in Chicago, Bibb Allen, MD, FACR, chair of the ACR Committee on Economics recommended residents embrace non-interpretive work even though it doesn’t carry reimbursement. These activities, such as getting involved with utilization management programs, would let residents play a role in developing an accountable care organization for their hospital or practice.

As radiology fights against repeated attempts to slash reimbursement for its services, putting young practitioners at the forefront of the movement toward team-based, cost-controlled care could benefit the industry in the long run, experts said.

Residents Leading the Way

Young practitioners are making their mark, however. PACS have long been radiology’s main technological tool, but the industry is rapidly moving toward greater health information technology adoption. And, newly minted radiologists are the most proficient users.

“Most new providers are leading us when it comes to health information technology. They have a better skill set than the majority of the more seasoned attendings have,” Kiproff said. “They pick up how to use new systems quicker than the rest of us. In many ways, radiology as an industry has to move and change to keep up with them.”