Radiology Residents Rule! But What Happens Next?

Richard C. Semelka, MD


March 06, 2006

The art and science of Radiology has evolved dramatically since I started my residency. My residency took place in 1984 in Canada at a major teaching hospital. We had 1 computed tomographic (CT) scanner serving a population of 1 million patients. The CT scanner took 18 seconds to produce a single tomographic image.

I rarely did an in-house call and almost never was called in to hospital; regarding interpretation of images, it took us residents 1 week to get the superior mesenteric artery and superior mesenteric vein straight.

In the New Radiology, residents often spend 1 night in 7 on call, where they are in-house and up all night working under constant pressure to issue reports on studies, often after spending a full 8 AM - 5 PM clinical day. The residents are always in a hectic setting and are sometimes even placed in adversarial situations. Within 2 days of starting their residency service in CT, they are expected to be able to recognize all major disease entities, in addition to just recognizing normal anatomy.

Why the sea change in the life of a Radiology resident over a relatively short period of 20 years?

The advent of CT scanning in the late 1970s and early 1980s forever changed the Radiology landscape from a guessing game of matching plain x-rays with many different disease states (always an intellectual guessing game) to a profession that actually makes, and is expected to make, the important disease diagnosis, or disease exclusion.

Since the 1970s, Radiology has been transformed from a helpful profession that may or may not have provided a definitive diagnosis, with no particular expectation of accuracy (at least from a legal standpoint), to the discipline it is today - ie, one that is expected to make the correct diagnosis with a 100% level of confidence.

In addition, with the rapid developments in high-powered imaging devices, (initially CT in the mid 1970s and then magnetic resonance imaging [MRI] in the early 1980s, followed by developments in ultrasound, interventional radiology, and nuclear medicine studies, including positron emission tomographic [PET] scanning), Radiology has attracted the best medical students in large numbers. In fairness to my generation, that process had already begun in the 1980s; and before us, bright medical students were still drawn to Radiology. Today, at most teaching institutions, 600 to 800 medical students, many at the top of their class in medical school, compete for 4-6 slots in a major Radiology residency program.

I am half-joking when I say that the exceptionally high standards required for entrance into a major Radiology residency program have diminished the chances of many established radiologists, including myself, of getting in. Keep in mind also, that, beginning about 1995, imaging modalities, primarily CT and MRI, have become the modern physical exam, and sometime around 2001, not only subjects who needed that imaging physical exam, but many other patients as well, underwent imaging evaluation, primarily CT scanning studies.

This current blunderbuss use of CT has resulted in a concern that patients may have a 1 in 100,000 chance of some rare disease or rare presentation that may be detrimental to patient health and may elicit litigation if the abnormality is missed. As a result, a plethora of CT studies and other imaging studies are performed in order to provide the immediate answers that are demanded from Radiology in keeping with its role of guiding patient management decisions.

What all of the above translates to is that Radiology residents are extremely intelligent but also extremely overworked and often must endure stressful circumstances during the course of their residency.

One other, critical factor is that university education in the United States, commencing from undergraduate education through the completion of medical school, is extremely expensive to the individual.

Post-secondary education is much less expensive in Canada, and is generally free in most other developed countries in the world. Following completion of a residency program in the States, the newly qualified radiologist often has $200,000 to $300,000 in student debt (which I would estimate to be equivalent to about $20,000 to $30,000 in Canada and negligible elsewhere in the world).

Filling out the economic equation for the Radiology resident, university salaries in the States are in the range of $200,000 - $250,000, while private practice compensation ranges from $350,000 - $600,000. In Canada, universities are often covered by private practices and the salary range is approximately $150,000 - $250,000, and in Europe, the standard university salary is about $50,000, while private practice salary is typically about $200,000.

The numbers above are in US dollars and are based on informal surveys I have conducted of my imaging colleagues.

One final consideration for the formula is that currently there is no broad-ranging research culture in Radiology, even at the top academic centers.

To summarize the talking points above, Radiology residents in the Unites States are:

  • Among the brightest of all medical students;

  • Hardworking and often overworked;

  • In considerable financial debt upon completion of residency;

  • Not trained in a culture that values research over revenue; and

  • Often facing a lower-paying university career vs a higher-paying private practice career.

Taking into consideration the key issues outlined above, is it any wonder that in Radiology we can start off with the brightest of medical students and, at the conclusion of residency, end up with individuals who are jaded from their training experience and whose primary motivation is making money and enjoying life?

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