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Comment by roentgen | Hacker News Reader

I had a different experience. Medical school was easy, I was single and went out drinking / partying two or three nights a week. Not to be crass, but I did well with the ladies. Luckily I can get by on four hours of sleep or less. So, I don't feel like I missed out on much of the early twenties experience. Most of my non-medical friends had jobs and I didn't, but that was the only real difference.

Things got a little more serious my intern year, but I still managed to go out twice a week, and the nurses were much more responsive to my advances now that I was doctor.

At the start of my residency I got serious with a girl from my medical school. Her training was in Psychiatry and I was in Radiology. We worked a minimum of 80 hours a week, but we always had time for each other. We got married during third year.

Now I'm a partner in a successful practice, and she's taking a few years off to raise the kids. I make over 800k a year, and take 14 weeks of vacation. I don't deal with patients. I have the ultimate job security. And, I am a tremendous resource for my family. I'm sure you know how easy it is to get screwed by the medical system. That won't happen to me or mine.

I'm not a risk taker, so what else could I be doing with the security and benefits of my current job? Lawyer, maybe.

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Lesson learned: If you do fine without sleep, and manage to wind up in the most lucrative specialty^, medicine may just be for you!

Speaking as the son of a psychiatrist who didn't marry a radiologist: you got lucky, and your wife got luckier. Good for you guys, but that's not what a student should expect from med school any more than a CS student should expect a $10mm exit.

^Barring, what, the specialized surgeries?

Many surgical specialties earn more than I do, like Urology, Neurosurgery, Orthopedics, etc.

> I make over 800k a year, and take 14 weeks of vacation.

I, for one, am disheartened by this gross misallocation of resources, but good work on the vacation time.

The median salary for experienced radiologists is $300k-400k. And increasingly radiology has been outsourced overseas with mostly technicians required stateside (scan during the day, radiologist in India examines at night, results available the next morning).

But roentgen claims to be a businessman as well as a radiologist. If so, most of his income would be from several radiology businesses. In that case the 800k/year number would not be surprising.

Always remember

- "On the Internet no one knows you're a dog." and

- "Don't believe everything you read."

http://www1.salary.com/radiologist-Salary.html

http://www1.salary.com/Physician-Cardiology-Non-Invasive-Sal...

http://www1.salary.com/neurologist-Salary.html

That radiologists make 100K more than cardiologists and 200k (!!!) more than neurologists absolutely screams market manipulation. Radiology seems literally one generation of Intel processors away from being automated into oblivion. God speed that it is.

I'm not sure if you've ever seen a CT stroke study, which typically includes 4,000 images. If you think a computer can accurately interpret one of these any time soon, I would say you are poorly informed.

See my response below, and look into "CAD" and mammography.

Hmm, how exactly does the number of images affect predictive algorithms? If anything, more data is better. No offense, but as a radiologist you're not exactly familiar with the state of the art in A.I. image processing. I'd say that both of us are unqualified to state the degree of effectiveness of computational geometry and computer vision in radiology.

You might not see it because it's such an inconvenient thing to see; afterall your income is tied to it. The main factor keeping your income so high is the AMA and its regulatory allies.

With rising costs and increasing pressure to save money in healthcare, you better believe that one day a computer will do your job.

PS You might want to re-read The Innovator's Dilemma and The Innovator's Solution.

My income's not tied to it, so I'll say it.

Computers reliably interpreting films as the final word is not going to happen in the near future (within this guy's career). Reading films is as much an art as it is a science. I'm sure a lot of advances can be made on it, and we might see nice proofs of concept. But to the point that it actually replaces radiologists?

Even if you assume the technology can be perfected, there are too many non-technological hurdles for that to happen. Liability, trust, etc...

Machine EKG interpretation has been around for a while, but it's not even close to perfect and no one relies on it, and it's a much much much simpler problem.

This guy gets it. Many replies in this thread are asking about computers interpreting scans, assuming I know nothing about the underlying technology, or am blinded by some form of bias.

I have been programming computers since I was 5 years old. I have a MS in neuroscience, and I am a board certified radiologist, so I think I'm qualified to understand the problem.

Believe it or not, nothing would make me happier than a magical black box that could spit out accurate radiology reports. Someday I'm going to get sick, and I would benefit from the technology.

If my job was replaced tomorrow I would be OK. I'm smart and hard working, and I'm good at almost everything I try, eventually. Also, I'm saving every last penny I earn, so I can keep things up for a few more years I should be financially secure.

Having said all that, I still think the problem is not solvable. On any given day I read xrays, CT scans, MRIs, ultrasounds, PET scans, mammograms, nuclear medicine studies, or live flouroscopic studies, and using CT or ultrasound guidance I can get a needle into just about any part of your body to take a biopsy. Doctors talk to me and our discussion influences the differential diagnosis, and the interventions planned. I am not just matching patterns, I am thinking and using my hard worn judgement.

Wishful thinking aside, computers cannot do this now, if ever. And if / when we reach the point that computers can do this, my guess is every other job will have fallen, with the exception of plumbing.

The day computers can do your job, they can do every job.

But never underestimate the ability of programmers to oversimplify every other job while proclaiming a computer can do it.

Computers are tools to aid doctors, they are not doctors. It's like a blacksmiths claiming the horseshoes can get you somewhere without a horse. It's just not going to happen.

First, a radiologist made a judgement call and saved my mom's life. I've got a lot of respect for what you do.

Second, there must some set of scans that are easy. It's not hard to imagine a device that says, "yes" or "see a real radiologist". Perhaps later revisions can even say "No". an example might be a mammogram analyzer. I think even 10% getting an immediate answer would save a lot of money.

I think it's the normal progression of technology. Generally, you don't need a Phd in math or physics to program computers like was required in the 60's. The net effect will be the average case you look at is much more challenging.

> an example might be a mammogram analyzer.

These exist, google for "mammogram computer aided detection". While the data on their efficacy is equivocal at best, I well tell you that they are useless. I do get to bill more for reading a mammogram if I run it through a CAD machine, which my group owns, so of course I do it.

Strangely enough, patients are reassured when the learn that the computer didn't detect any problems. And, more importantly, ignorant juries can be swayed by this piece of information. "The computer didn't detect anything? Then there is no way the radiologist should be held liable for missing that little tumor!" I'm not joking.

Little do they know.

Do you use Thermography, I've read it to be safer?

It's naturally for humans, especially ones who've invested years of effort into something and get paid a lot for it to continue, to claim that something is "more of an art than a science." They are wrong. Do they collect data on how they make decisions and what the outcomes are, and then check that they are improving?

For contrast, look at http://www.lifeclinic.com/fullpage.aspx?prid=508121&type... There they decided to stop gathering lots of information and making a judgement and instead use a few simple rules to make a decision on whether someone was having a heart attack and how bad. It was more accurate.

I don't know much about reading films, but I do know something about AI, and this kind of direct data->solution problem with an enormous existing data set is just about as easy as AI problems get. I wouldn't be surprised at all if we are already at the point where its a trust/liability issue rather than a technological one.

I disagree with all your points. I think the main reason for differences in salary is that it is easy to measure what a radiologist does. It is also relatively easy to measure what a cardiologist does, particularly if they are doing procedures such as angiograms.

Mostly a neurologist diagnoses stuff and manages chronic disease, and how do you measure that? Arguably, the neurologist does the most difficult and complicated job. They get paid based on consultations per time, which is clearly a pretty hopeless measure.

Also, the notion that radiology is going to be automated by increased processor power is a bit ridiculous.

We are talking about a task where lives are at stake, communication and DISCUSSION with real people is required frequently, and there are large variations in the quality and modality of scanning.

Also, any data driven approach is very limited... what happens when a new MRI sequence is developed? We have to wait 15 years for real radiologists to do enough reporting so we can get a proper dataset?

If you read my other comments, I state that I make twice the average salary, because I read twice as many films.

> increasingly radiology has been outsourced overseas with mostly technicians required stateside (scan during the day, radiologist in India examines at night, results available the next morning).

This is not true. Some "preliminary reads" are read overseas at night, but the doctors reading the studies are trained and certified in the USA. "Final reads", the CT scan report that counts, cannot be read elsewhere.

> "Final reads", the CT scan report that counts, cannot be read elsewhere.

Why not?

I have sort of answered this question below.

Final interpretations must be performed by a radiologist residency trained in the USA, licensed in the state there are reading from, and credentialed for the facility and the insurance company.

Why? Well, I guess it's supposed to be to ensure quality. In general, it is probably good that every hospital in the USA has an independent credentialing process. You could debate the fact that doctors in the USA are better trained, but in fact that has overwhelmingly been my experience.

Cynically, I believe that the lawyers need someone to sue. Like I said, most doctors complain about malpractice, but not me. The trial lawyers can't sue doctors overseas, but they can sue me. So, in a sense they are my ally, they ensure that no one else ( except people they can sue ) can read the studies.

That being said, there are companies that take USA trained radiologists and station them overseas. Australia and Geneva are both popular. They take advantage of the time difference to read hospital cases that occur overnight, when I am home in bed. They usually provide a preliminary read, something like "no appendicitis." The next day I do a final read, look for mistakes in the preliminary read, and in general do a more thorough job. Sure, there's no appendicitis, but the preliminary read didn't mention the small tumor in your left kidney that kind of looks like a cyst, but isn't.

FYI - overseas reads by USA trained radiologists tend to be more expensive, not less.

Anyway, thanks for jquery.

He's running a business; what's not to get? He sits higher up on the ladder with a bigger net than most doctors. The doctor that reads your x-ray at the local community hospital and this guy are in two different positions. One is an employee, the other is a business founder. The amount of money that you and the insurance companies pay to both are no different.

Ok, so everyone agrees that doctors are underpaid and overworked, and when someone isn't underpaid or overworked it's a misallocation?

Trust me, a good radiologist is easily worth that much and more. They make hundreds to thousands of decisions a day and produce data which is scrutinized carefully. Many radiology mistakes also eventually come to light through time or autopsy, so they are also accountable.

People in other jobs are paid more to do far less and be far less accountable, the finance industry being the number one example. (Thanks for your good work lately.)

One final point is that medical training in other countries isn't like this. In Australia, we don't work ridiculous hours most of the time and remuneration is reasonable. As well as making actual healthcare inefficient and needlessly expensive, the US has managed to do the same to medical training.

Thank you for your honesty.

May I ask, what exactly do you do that you feel justifies your 800k per year? It seems to me that your career is ripe for disruption.

The Health Care Finance Administration ( Medicare / Medicaid ) sets reimbursements rates, and most private insurance companies follow suit. So, I don't get to charge whatever I want to read an MRI. And, I don't order the studies that I read, other doctors do that.

The only thing I can control is the number of studies I read. If I work harder and read more, I make more. It just so happens that I am very fast, and I have surrounded myself with fast partners. On average we read two or three times what other radiologists read, so we make two or three times more.

As far as disruption is concerned, for now the law is on my side. Of course a doctor working in India could read studies cheaper than I could. Most doctors complain about malpractice, without understanding the benefits. Trial lawyers hold me liable for my reports, and rightly so. If I miss a small treatable cancer, it can turn into a large untreatable cancer. This liability also confers a monopoly. How can a lawyer sue a doctor in India? Consequently, in order to perform a 'final read' on a radiology study in the USA, you must have trained in USA, be credentialed in the USA, and liable in the USA. This makes it very hard to undercut on price.

So, I'm not sure if I deserve what I make. There aren't a lot of people that can do my job, or withstand the training. Anyway, I'm saving everything I earn, because I don't think it will last forever.

are you concerned that a computer program could eventually do your job?

I'm not sure if you're being serious or not, but I'll answer.

I happen to think real AI will not happen in my lifetime, if ever. This is not an uninformed opinion, I have MS in Neuroscience, and I'm a programmer. I'm sure others reading HN will disagree.

It will take nothing less than a full artificial intelligence to do what I do.

If you want to read more about early attempts, there is something called "Computer Aided Detection" that is used when reading mammograms. It is awful, and I'll let you in on a secret. Most places that CAD their mammograms do it so they can charge more, not because it helps.

You mentioned in an earlier comment about a CT scan being 6k+ images. I'm assuming these are cross-sectional slices or something similar?

I know a guy who's working for one of the big CT manufacturers (Toshiba, I think) working on 3D image-registration and partial analysis. In essence, lining up the features from different slides and sewing them into a 3D model.

One of the big features being looked at was automatic labelling of certain gross anatomical features - I seem to remember something about cardiac veins needing to be marked as part of a scan report? By mostly automating this, it saves time for the user so they can just check they're correct, maybe move them if not, rather than having to do all the work themselves.

I can see this sort of work being much more useful, and happening in a much shorter term than any sort of AI "You have cancer" system. I wonder how you feel about that sort of thing?

I use this software when we perform a CT scan looking at the coronary arteries. Under perfect conditions it can correctly idenitfy the coronary arteries, and subtract away the rib cage, heart, and lungs.

It sounds like you already understand what it does. It helps me read a study quicker by automatically processing the data, a step I used to do by hand. Many times the processing fails due to an artifact while scanning ( patient moves, ectopic heart beat, poor contrast injection timing, variation in anatomy), and I need to process it manually.

When it works well it is very helpful, but to be clear, it does not interpret the studies. I think many people replying in this thread don't understand the enormous complexity to accurate radiology reporting.

Generally, rare goods - and skills - are valuable. So going to school for a long time to learn an unusual skill well means that your services are more valuable.

Also, providing a large amount of value in a small amount of time (like accurately interpreting the results of a scan) leads to providing huge amounts of value over the course of a year. Part of the explanation is the sheer volume of individuals he can give a reasonable amount of value to.

Wouldn't radiological and physician services, in general, be less "rare" if medical schools started to train more physicians (admit more students)? I have read studies that suggest that in certain markets and certain practice specialties we are and will face shortages of physicians in part because medical schools are training too few physicians. When I ask academic physicians they seem to think admitting more students would erode the quality of students. In other words, scarcity is a public good in this case as it helps to ensure that the "most talented" will ultimately become practitioners. I don't know how this view squares with the large number of foreign-trained residents in some residency programs.

The Planet Money podcast covered this topic once. In proper markets, increasing the supply of a good or service decreases its cost. However, in the US, the more doctors we train, the more we spend on healthcare.

A reason this is the case is because the average healthcare consumer is totally removed from the cost of healthcare and the doctor has a perverse incentive to make work for him or herself and other specialists.

Right idea, but wrong bottleneck. Admitting more students to medical school would enlarge the pool of applicants to Rads residency, but it would by no means force Rads programs to admit more applicants.

So going to school for a long time to learn an unusual skill well means that your services are more valuable.

It's only a rare skill because of licensing/board requirements. I'm fairly certain if you told other people they could make $250k as a radiologist, they could self-teach.

The same thing could be said of programming if the only people that could practice had to be certified.

I'm going to respectfully disagree.

This may be possible in some medical fields (I doubt it), but not radiology. There is simply too much to learn. I completed 4 years of medical school followed by a 5 year residency. Some radiologists go through additional sub-specialty training. I've been practicing for 5+ years, and I'm still learning everyday.

I am a doctor's doctor, meaning my customers are doctors from every specialty, who order studies and read my reports looking for answers they can't answer clinically. I can talk to Orthopedic surgeons in their language, Neurologists in theirs, and Gastroenterologists in theirs. I'm familiar with the radiological manifestation of most pathological processes a human can experience.

The notion that someone could self-teach what I know seems impossible.

There are licensing and board requirements, but conspiracy theories aside they are not designed to create artificial scarcity, they're supposed to keep dangerously ignorant doctors from practicing.

But what can you say that about? I did 4 years undergrad in CS, followed by 5 years for a PhD. Followed by more than a decade in industry. And I still learn everyday too.

The notion that someone could self-teach what I know seems impossible.

I should be clear, as the term is ambiguous, they'd likely learn from experts, but not by going to a board approved medical school. But through things like online schools, programs, books, etc... It wouldn't be someone trying to recreate a curriculum from scratch.

There are licensing and board requirements, but conspiracy theories aside they are not designed to create artificial scarcity, they're supposed to keep dangerously ignorant doctors from practicing.

Given the lack of policing after becoming a doctor I'm skeptical of this claim. At the college level I'd like to see a wider swath let in to medical school, and then a more rigorous approach to filterning, based on not only medical proficiency, but ethics. The big problem I see with doctors isn't in expertise or proficiency, but in ethics.

And given the data on sleep deprivation and learning, I think loosening the requirements even a tad would result in less scarcity and better prepared doctors on average.

We see things differently.

Radiology is a very difficult field to get into after medical school, something like 2/3 of American grads who apply get turned away. Additionally, for those who get in, up to 1/3 never pass all the board exams. It almost seems like you want to lower the bar, and I'm telling you it needs to be raised.

My guess is that if your system was developed and worked, the intelligence and drive required to complete it, the time spent studying and working to become competent in radiology would end up being no different than the current system. There are no short cuts.

"Radiology is a very difficult field to get into after medical school, something like 2/3 of American grads who apply get turned away."

I don't agree with kenjackson that the field can be self-taught, but saying that most people don't get into Radiology residencies tells me only that there aren't enough Radiology residencies to go around. The 1/3 board failure rate notwithstanding, my intuition is that there are far more people capable of practicing radiology than are currently allowed to try to get into the field. The intelligence level of medical students does not exceed that of PhD students in engineering, math, chemistry, etc., but the medical profession puts up much, much higher economic barriers to entry.

If the government decided to tax radiology providers and use the profits to increase the number of radiology residencies by 10 or 100-fold, I find it hard to believe that the lucrative profit margins of your industry wouldn't decline. Medicare reimbursement rates would go down as the number of providers increased.

All you've said is that some tests aren't being passed. Can you correlate them with improved medical care? Again, in my alternate world, I can construct a CS test that 90% of those w/ undergrad CS degrees would fail. That's not hard to do. The question is "does my ability to pass such a test correlate with my ability to do a website?"

You're pointing to scarcity and arguing that this is proof that we require scarcity. I'm saying that if you dropped the bar on these tests, but increased other policing practices that yielded a net increase in the number of doctors, I think you'd see an increase in medical care. My thesis is purely speculative, I grant you that.

I suspect we're likely to find out if this does work out in non-US countries once as medical information and training becomes more prevalent on the web.

You make some good points.

Of course, I cannot prove that the tests insure quality. In fact, this is not what the radiology board exam does.

The board exam is designed to weed out dangerous doctors, which is probably the best we can hope for. So, I guess you can take my word for it or not, but dropping the bar at all would let dangerous people practice, which I see as a mistake. The people that I know who failed the exam should not be working in Radiology.

>There are licensing and board requirements, but conspiracy theories aside they are not designed to create artificial scarcity, they're supposed to keep dangerously ignorant doctors from practicing.

Thanks for the comments in this thread, they've been very informative.

I'm happy there are certifications, and I believe you that the bar should be raised, but given the huge demand for doctors, why aren't we increasing the number of medical schools?

If we have a supply problem, and we don't want to lower the bar, it seems like the answer is to let more people in at the front end, and let the filter do its job.

Just wanted to point out that while it may seem intuitive that increased supply = cheaper prices, thats not how it works with doctors

Doctors have the ability and incentive to increase demand, and I remember seeing data that this is what actually happens historically when you increase doctor supply.

How do these ability manifest? I suspect what you might be seeing is latest demand. There are a lot of people that would see the doctor more often, but often don't due to prices. Once access and prices become more reasonable they seek out medical services they normally wouldn't have.

Or doctors see their profit-margins / wages declining, and lower the threshold level for various kinds of specialised testing. So, you complain about a mole or a lump, and instead of a quick diagnostic poke and an "It's probably fine", it's off for an invasive biopsy, "Hmm, the results were inconclusive, better safe than sorry" surgical removal, and maybe a few extra scans for follow-up.

I'm sure that there a many areas where a GP would like to schedule a follow-up, but can't justify it on the current evidence, and lets it slide.

Because there's this level of subjectivity in medicine, any increase in supply can easily be countered by the suppliers pumping up demand, keeping D/S exactly the same.

(I'm not a doctor, although I'm friends with a few)

I'd argue this happens today at almost the maximal level they can extract. In fact this was my point earlier. The problem with doctor's is less proficiency, but more ethics. I honestly have more faith in my car mechanic than virtually any doctor I've worked with. I'm not sure how increasing supply can make an already worst problem worse -- except to expose more people to it.

BINGO. You win the thread. The Clintons learned this the hard way, but most people don't understand how this could be true.

I really, really don't think that's true. Most people are not able to do this, and most of those few who could don't want to put themselves through it.

And then separately, how many people would trust a self-taught diagnostician?

Most people are not able to do this, and most of those few who could don't want to put themselves through it.

Most people don't have to be able to do it, just more than are allowed to do it now, but a factor of say 10.

Furthermore, I don't think people would necessarily need to go through med school and residency.

It's like building a website. There's probably some parallel universe where programming requires certification and only a handful of schools have it. It requires doing MITs SICP as the intro course. Requires compiler construction courses, algorithms, theory of computation and complexity, etc... And then a 4 year apprenticeship with other programmers. And then you can start building webpages, if that's what you want to do.

But we live in a world where it is open and so there's instruction available at many different levels. Would you let someone without a PhD in CS build your website? Of course you would.

And then separately, how many people would trust a self-taught diagnostician?

I trust my car mechanics diagnosis despite the fact I have no idea what level of education he has. But I'm fairly certain he's not an ME from MIT or Berkeley. With good self-study tools, I think that one can self-teach in specialized areas and achieve good mastery rather efficiently. I could imagine Khan Academy for Radiology taught by JHU and Harvard professors to be quite good.

> I could imagine Khan Academy for Radiology taught by JHU and Harvard professors to be quite good.

You have got to be kidding me. How would this work for surgery? There are no short cuts to medical competency.

Sure, some of what I do is self-taught, I read books and articles, attend conferences, and complete Continuing Medical Education requirements. But I am able to do this because I attended medical school, then spent five years sitting less than a foot from experienced radiologists while they worked and answered every question I had.

Characterizing it as a "short cut" is disingenuous.

The argument here is that medical boards are too rigorous, and test things that do not matter practically.

To give a ridiculous example, if a medical school required you to climb Mount Everest before becoming a doctor that might result in only 1 person becoming a doctor per year. However that scarcity isn't proof that climbing Mount Everest is needed to become a doctor. Nor is it proof that cutting out that requirement will provide significantly worse doctors than previous.

Additionally, in many things we need quantity more than we need extreme compentancy. For example when cut, its better to have some kind of treatment (e.g. first aid, stitching) rather than waiting for a surgical specialist.

In fact, the medical licensing exams and board exams are too lenient. The general quality of people going to medical school in the US has been dropping for a generation. The standards are sliding, to our detriment.

I'd be quite interested to see evidence to support this assertion. Or is it just generally the case that everyone sees Osler's days as medicine's primetime, with a long slide since then?

I don't have any hard evidence, but I insist that it is true.

Bright and determined baby-boomers became doctors and lawyers and accountants. Today smart and determined people aren't even going to college. The HN demographic is a perfect example of this.

Intuitively, I think I get a different sense of the HN demographic. It's one thing to say that the brightest aren't going to medical school. It's another thing to say that the best and brightest aren't even going to college.

I might argue that going to college is no longer necessary for the purpose of learning, because the material is so widely available. Even though I think that's true (for some fields), I still wouldn't advise people not to go to college because of the signaling problem (which one then has to sidestep by starting their own business or by contributing impressively in open source, etc).

I get hyperbole for the purpose of making a point, but if you go too far, you come off sounding a bit incredible.

Have you seen a typical medical school class recently? The people getting in these days is almost shocking. I have a hard time believing that qualified people are being shut out of admission.

Yes? I mean, I am a medical student, and I'm routinely impressed by my peers. But I'm not trying to claim that my peers are better than their predecessors. I'm just doubting your assertion that medical students now are worse than before. The null hypothesis certainly is that things are the same as they always were.

Instead of writing out a long response, I'll just point out that to compare building websites with diagnosing life-threatening illness many times a day is pretty ridiculous.

Of course you don't need to have gone to MIT, etc to build a website. The room for error is just many many orders of magnitude different between that and radiology. There's a reason you don't generally hire self taught code monkeys to build software with real-time or life-ensuring requirements.

This only applies if those rare skills aren't rare simply because the need for them is rare. Supply and demand determines prices.

Demand isn't just about how many people want it (although a little competition is good), it's also about how much each person wants it. It seems like medical diagnosis could command a high price, even if only one person needed it.

Exactly, you stated it much better than I could.

He makes that much as a partner of a practice, not as a doctor at a hospital. This is no different than being a founder of a successful small business.

It's also worth noting that radiology has been undergoing some significant transformations. Formerly, a practice would contract with one nearby hospital to read their cases. With the advent of teleradiology, though, it is no longer necessary for the practice to be all that close to the hospital. As a result, radiological practices are contracting with more hospitals. They are growing and sometimes putting smaller practices out of business. So I imagine there are some big winners and losers out there in the field of radiology.

I don't have first hand knowledge of this; I am a programmer. I hear about this from a family member who is a radiologist. roentgen may obviously speak with more authority about his situation.

My group does this, but not because we're evil. Larger groups often have fellowship trained radiologists who are experts in a certain sub-specialty, for example Neuroradiology. Smaller groups are usually all 'general' radiologists.

If we can read pediatric brain MRIs more accurately from across the country than the local small group, why shouldn't we?

One additional note. My 'customers' are not really the patients, my customers are the physicians who order the studies. Most hospitals and referring physicians demand that I be available to speak with face-to-face, so there are parts of radiology that cannot be performed remotely.

What protects you from outsourcing the reading of scans to foreign countries, such as India? Obviously some medical institutions will want to keep it all local, but won't this open up a market for cheaper, foreign competition resulting in a downward pressure on compensation?

See my other answers. "Final reads" must be performed my a physician who did a radiology residency in the USA, and credentialed in the USA. Note, you don't need to be located in the USA, but it doesn't matter, there is no competing on price.

See my other answers. For each scan or xray performed, two fees are billed. The reimbursements are generally set in stone, and non-negotiable. Additionally, "fee-splitting" is Medicaire fraud. Meaning, if you as an independent businessperson own an imaging center and I read cases for you, you cannot keep any of my "professional fee" for reading the case. So there is no way for another radiologist to compete on price with me, it is simply illegal to offer to read the cases for less.

Do you think this Medicare law is useful for protecting consumers?

Not really, no.

Trust. FMG (foreign medical graduates) have an extremely low reputation in the US. It's a component of defensive medicine.

Correct. When a CT scan is performed, there are two charges generated. A 'Technical Fee' for performing the study, and a 'Professional Fee' for reading it. The technical fee is almost always larger.

If you work for a hospital they keep the technical fee, and you get whatever professional fees you can collect. Insurance companies hate paying, so they will find any reason to deny. Collection rates range between 60% and 80%.

My partners and I own imaging centers, we collect both fees. So we are running a business, and I don't consider it small anymore.

Disruption is learning about and becoming healthy, or for example, one may spend their life savings on some supposed cancer treatment involving chemo, surgery and radiation.

If you are still in radiology, I'm not surprised by this. Radiology is one of the few times that you can be a doctor and expect to work something like a 9-5 day.

There are other ways to have a decently normal life as a doctor, but on average it's a pretty hard life.

True, but I knew about the lifestyle when I picked radiology, and it is a very hard residency to get. There are others with a similar lifestyle, like Dermatology, Ophthalmology, and Radiation Oncology. Guess what? They are the hardest residencies to get into when you finish medical school.

I should make clear why I'm replying in this thread. The world needs good doctors, and I want bright and ambitious readers of this site to know that there is a potential upside.

I know this is off-topic, but I figured I'd take the opportunity to ask:

As a medical student who aspires to enter radiology and ultimately own imaging centers, like you, what advice can you offer that'd help me and other HN-med students position ourselves to be appealing candidates for a radiology residency?

I don't know any secrets. It's hard to get a radiology residency. You need good grades. I don't think research experience matters. It also helps to be somewhat normal. The people interviewing you for residency have to be willing to sit next to you for four years, so if you're a "closet case" they might pass on you, even if you look good on paper.

"and ultimately own imaging centers"

Contact the MD here for advice:

http://upper-dublin-mri.com/aboutus.aspx

A nice guy, he was glad to help when I was thinking of starting up an imaging center. (The upshot from the meeting is that you have to have a tie in with a hospital and be aware that the hospital could end up doing the same in house etc. He's a businessman and a MD and would have profited from the association so I believe the advice was honest. Of course it's only one data point out of many you will collect.)

Thanks, I appreciate it!

Meta-comment: how is it possible that 2 reasonable, informative comments from roentgen are being downvoted?

I didn't down vote it but I suspect that it's

"Medical school was easy"

"went out drinking"

"partying two or three nights a week"

"did well with the ladies"

"get by on four hours of sleep"

"nurses were much more responsive to my advances"

"busy but always had time for each other"

"make over 800k a year".

"ultimate job security"

"tremendous resource for my family"

"easy to get screwed by the medical system...won't happen to me or mine"

"not a risk taker".

Did I miss anything?

Sorry, but I wanted to be completely honest. There were a few guys like me in my medical school. There needs to be a counterpoint to the doom and gloom reports of "no life" and "living hell".

(Not a med student, but I double majored in two different engineerings so I had a pretty tough road)

Honestly I think people over rate how difficult school is.

I was definitely in the camp of 'it's so fucking hard, I have no life, it's horrible' etc etc etc. And I'm a smart guy. Guess what, when I actually went through and figured out how much time I was spending working, it wasn't that much. If you clear out the procrastination and bullshit and just sit down and work hard while you are working, it's not bad.

Then you actually have free time.

I struggled with this for years, but working at 50% effort for twice as many hours is a horrible way to go about things because you end up living a miserable life.

At my graduation they announced the valevictorian. It was one of my friends. We had no idea. He never talked about grades. He never bitched about work. He went out drinking nearly every day of the week. He spent a lot more time chasing women than chasing grades. But when he went to the library to work, he worked.

Remember, 6 hours a day of hard work is worth a lot more than 12 hours of half assed work, and thats what he did. That leaves 18 hours a day to enjoy yourself.

"but working at 50% effort for twice as many hours is a horrible way to go about things because you end up living a miserable life."

For how long? The years of college and graduate school?

Misery is not working hard enough and then ending up being one of those people unemployed in later years. (Which I agree can happen to anyone obviously.)

"6 hours a day of hard work is worth a lot more than 12 hours of half assed work"

True. But you will never be able to work as long and as hard as you can when you are young. The fun comes later. And once you have a family and kids all bets are off as far as how much you can work.

Look different things are important to different people.

But in life (as in entrepreneurship) you never know the thing that you do that will eventually benefit you. You have to learn and do as much as you can. I can trace things now that are of great benefit today that I did 15 years ago by foregoing a summer and actually summers of fun.

It's easy to look back (even roentgen at 800k) and say "look it all worked out for me and I was able to party". But we don't really have much data to support that strategy (an outlier as pointed out by verisimilitude) and in fact it doesn't really make sense that you can put in half the work and do AS WELL as putting in more of an effort without completely wearing yourself down.

Thank you. However, statistical outliers (you) don't make strong counterpoints.

I'd describe you as a possessing several traits that make you well suited for a career in medicine.

Hypomanic personality. Characterized by low need for sleep, excessive energy.

High IQ/ general intelligence.

Low tolerance for risk.

You are probably making less money than you could as entrepreneur or in finance but that's consistent with your risk tolerance.

The professional medical career path is almost ideal for you and the author of the original post would probably acknowledge this. This is probably less true for many of the individuals who are steered into medicine by the elite educational system.

You have accurately described me.

In terms of job security, I heard that many hospitals are outsourcing radiology to India, ie. sending the X-rays, etc, over the internet and getting them diagnosed in India, by equally competent Indian doctors.

Is this true, and if so, do you think this might jeopardize at least radiology in the US?

> I make over 800k a year

Does it bother you that you are profiting handsomely from sick people?

Not at all. I'm very good at my job, and I worked very hard to get where I am. Sick people should be happy that I'm reading their CT scans. If the pay wasn't good I would have chosen a different field, and somebody else would be doing my job, less well.

For reference, before medical school I worked in IT, and at the age of 23 ( 15 years ago ) I was making six figures. I left that to go back to school, partly because I knew I would be financially rewarded.

Again, see my response below. I don't order the studies I read, and I don't set the reimbursement rates. Additionally, it is Medicare fraud for me to read a study and not charge for it. In short, I have very little say over what I earn.

Do you worry about being replaced by computer software? You said you make $800k a year, and for that amount of money you could higher 2-3 PhDs in machine learning and computer vision for each radiologist. Do that maybe 5 times over and give them 5-10 years and productivity and costs for CT scan analysis will probably go way down.

After all a radiologist armed with software that prescans each CT scan looking for interesting areas could work way faster then otherwise.

There's a small army of PhDs doing this right now, NIH-funded and in commercial research shops.

A radiologist still must look at every single slice for liability reasons for the foreseeable future. That's the real time cost.

I work for a neurosurgeon in image-guided surgical planning research. One of the challenges is segmentation (labeling) of target areas to use in navigation. (radiologists generally don't do this, for various reasons). I've used some of the best commercial software, and seen some of the top research algorithms. With these, for the `easiest` tumors, we still have to semi-manually choose the region on every 3rd or 4th slice. The best algorithms will interpolate the other slices based on essentially fitting along a levelset. For a typical tumor, it can take 20-40 minutes to do this task - using the best available software!

This is `not` radiology, it's image labeling. It's orders of magnitude simpler than radiology.

There are some promising techniques to, for example, automate detection of changes in volume of some radiographically questionable area (after manual labeling for the first scan). At best, this will add information with no extra time cost.

I can assure that there are already an awful lot of PhDs in machine learning and computer vision working on the problem of automatically analyzing medical images, and there's been lots of progress over the last few years. There's a really long way to go, however- it's one of those areas where the problem is a lot harder than it seems.

Working in the field has convinced me that radiologists earn every penny, and that there are good reasons for the lengthy residencies and stringent board exams.

> it's one of those areas where the problem is a lot harder than it seems.

Yes, exactly. To computer savvy people unfamiliar with radiology it looks like something a computer might be good at, but I suspect the best we can hope for is a computer to aid me in my work, not replace me.

I've sort of answered this problem above. I happen to think the problem is not solvable any time soon. If you or someone you know would like to prove me wrong, I will invest in your venture.

What type of work were you doing in IT? What was educational background at that time?

More importantly, does it bother him that they are sick in the first place, or is he happy?

Well, people aren't going to stop being sick anytime soon, so I guess I'm happy that I'm around to help them get well again.

keep going.. with time, money, knowledge and youth, I bet you could be doing more.

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