Finding and choosing a job is a big deal in any profession and medicine is no different. When choosing a medical practice, it’s best to first be familiar with the different types of medical practice settings that exist before narrowing your decision down to a specific group practice.
While this article is focused on group practices in radiology, it can be applied more broadly to other medical specialties (e.g., internal medicine, family medicine, anesthesiology, etc.) and medical practices of all sizes.
My recommendation: Read (or skim) this article with the purpose of thinking about the different practice models and their pros and cons with the intent of maximizing your day-to-day happiness. Life is too short to not be happy!
What are the Different Medical Practice Settings?
Broadly, there have historically been three basic practice settings in medicine: academic medicine, private practice, and a hybrid of the two, which I’ll refer to as “hybrid(s)” for this article.
However, a new practice setting has emerged and has recently become more commonplace during the COVID-19 pandemic: telemedicine.
Radiology was one of the early medical fields to shift to a telemedicine model thanks to the internet and the digitization of imaging. (I briefly overlapped with this thing called “film” where we would put a picture up against a light box…and we would walk to work, uphill, both ways…in the snow). Teleradiology is poised to play a key role in the future of radiology.
Radiology differs a little from other forms of medicine in that solo practice is quite uncommon. Most solo practices in radiology consist of a single radiologist acting as a solo practitioner either running their own practice (typically an imaging facility containing imaging and medical equipment) or working directly for a hospital as an employee (hospital-based).
A typical solo practice may use locum tenens physicians to cover vacations or completely close during times of vacation.
Academic radiology jobs are associated with academic universities and, as you would expect, have an academic component that includes academic research and/or educational responsibilities.
Academic jobs have a structural hierarchy that begins with “Assistant Professor” to “Associate Professor” and finally to full “Professor.” Moving up the hierarchy is typically a long process that requires multiple academic accomplishments over time and outside support from unaffiliated academic radiologists outside of the institution. Regardless of their titles, a radiologist in academics is referred to as an attending physician.
There are typically research (performing and publishing research articles) and clinical (educational) tracks. Because academic institutions value research and education, most tracks provide some dedicated time to work on research, prepare educational lectures for morning and noon conferences, prepare and give multidisciplinary case conferences with interesting cases, and/or help residents and fellows create educational exhibits and presentations for various radiology conferences (and there are a ton of radiology conferences!).
Many academic institutions are associated with medical schools and include opportunities to teach medical students and residents in other specialties and residency programs.
There are also plenty of opportunities for academic radiologists to become experts in very narrow niche areas through teamwork and collaboration with various internal medicine and surgical subspecialties (e.g., gastroenterology, oncology, surgical oncology, etc.).
There is frequently overlap between interventional and diagnostic radiology and it is fairly common for a diagnostic radiologist to also perform light interventional imaging procedures within their subspecialty, such as image-guided biopsy, paracentesis, thoracentesis, lumbar puncture, joint injections, etc.
Academic radiology is a great job choice for those interested in research and/or education, who want to advance the field of radiology, and/or train future radiologists.
There is a lot of heterogeneity across private practices, which vary depending on size and independent private practice group structure. Let’s break down the different models in this practice setting.
Private practices use a partnership-based model, but what does it mean to be a “partner?” If you are a partner at a radiology practice, that means you are, in essence, a business owner with your other partners.
You are in charge of all of the administrative functionalities of a typical business: hiring staff, staffing and running imaging facilities, ensuring maintenance of facilities, billing, accounting, etc. The “non-interpretive skills” portion of radiology residency education is actually quite applicable to this, which is great as there is otherwise minimal or no training in residency or medical school on how to run a business.
Fortunately, the vast majority of private practice groups are well-established, well-oiled machines. Most practices have accounting departments, human resources, various managers, and leadership teams. Larger practices (80+ member radiology groups) frequently will even have C-suites with chief executive officers (CEOs) and more.
Moderate and large private practices generally have a board of directors (or equivalent). Members of the practice are voted to this smaller subsection of the group practice and given extra responsibility of running the practice and helping make decisions with respect to future directions of the practice.
The board is typically limited in size to allow fruitful discussions to take place and to address action items. (“The more the merrier” doesn’t apply to decision-making – too many opinions can lead to drawn-out discussions and prevent resolution of issues). Boards of directors generally include 4 officer positions: president, vice president, secretary, and treasurer.
Bylaws! Again, most of us enter new jobs the same way we entered medical school and residency – blissfully ignorant. Well, it turns out running a successful practice is an incredibly complicated and ambitious undertaking. Each practice needs bylaws – rules established by the practice to allow/guide self-governance. I’m assuming this is done with the help of lawyers at most places (again, ignorance is bliss and enlightenment is…less blissful). Luckily all of this stuff is already established at most group practices.
Partner radiologists are typically expected to contribute more than just reading cases and take roles in practice leadership. Examples include: board of director positions, finance, quality, outpatient operations, professional development, medical director, section chief, protocol review, etc.
Lastly, partnership typically comes with increased financial security – a higher salary and less financial risk. Some may have increased amounts of vacation – these vary with the different types of medical practices – and improved benefits (401k profit-sharing, cash balance plan contributions, etc.).
Becoming a Partner
All groups with partnership will have a “partnership track” that ranges from 1-5 years, most often 2 years. Some groups may offer an abbreviated/shortened track for experienced radiologists. Newly hired radiologists are typically considered “pre-partners” and sign an employee contract stipulating the path to partnership.
A pre-partnership is a way for the partners of a practice to assess new radiologists (or other physicians) prior to making them partners (co-owners) of a practice. Pre-partners are generally paid a salary at a lower rate than partners with benefits packages that are specific to each individual group.
Pre-partners are frequently expected to contribute to the practice beyond just reading cases, as mentioned under the partner section above.
Employee or Contractor
Employee radiologists are employed with the practice and receive a Form W-2, benefits package, etc. all supplied by the employing practice (the employer). Independent contractors, on the other hand, are self-employed contractors who receive a 1099 tax form rather than a W-2.
Contractors are responsible for paying all self-employment taxes (Social Security and Medicare), finding their own medical benefits, setting up their own tax-deferred retirement programs (such as a solo 401k, SEP IRA), etc. Think of it as exchanging the benefits for cash. Contractor positions are generally best for those who can easily be added onto a significant other’s medical plan.
Employees and contractors are generally able to negotiate more flexible work schedules, have a set schedule, and generally are not expected to take on leadership or practice management roles. This set schedule leads to a more predictable income.
Interventional Radiology in Private Practice
The life of an interventional radiologist can be quite variable and is entirely dependent on the group practice structure. Jobs vary from 100% procedural-based where interventional radiologists only perform interventional procedures to various splits of interventional and diagnostic radiology.
Regardless of the job setting, interventional radiologists provide direct patient care and typically have various clinical duties such as performing patient interviews to evaluate if a procedure is right for the patient, rounding on hospital patients, and/or follow-up clinic appointments following certain procedures.
Interventional radiologists frequently take some form of call, which ranges from one night at a time to a night float system working a week or so of nights at a time. They may work in the hospital setting and/or in an outpatient clinic or medical facility.
Exactly as you would expect, a hybrid group is somewhere in between academics and private groups. Hybrid groups are generally associated with a radiology residency and tend to have a more clinical role with focus on educating radiology residents and possibly medical students for practices affiliated with a medical school.
Radiologists that work for hybrid groups are typically employed, though there are some private groups that also fall into the hybrid model.
Healthcare Organizations, Hospital Employed, and Private Equity
Private hospitals and private groups, like Kaiser Permanente, also use the employee model as described above.
You are more likely to lose physician autonomy in these group practice settings. On the other hand, there’s typically less administrative burden. There are still opportunities for career development and leadership with the associated hospital and healthcare systems (as Medical Director, Chief of Radiology, Chief Medical Officer, etc.).
One major trend over the past few decades across medicine is the growth of private equity/hedge fund-run groups. Private equity groups purchase private practice groups from the partners/owners of the group (generally for very large sums of money, though they typically have to work for a full 5 years to receive the entire sum).
In radiology, the main player is “Radiology Partners,” frequently referred to as “Rad Partners.” Rad Partners has grown substantially over the past 10-20 years. The partners and employees of the group become employees of Rad Partners, generally with salaries below their typical salaries as owners. I think of it as taking a lump sum today at the expense of future earnings for the foreseeable future.
Private equity groups take over the majority of the business component, such as reimbursement negotiations with insurance companies, billing, human resources, etc.
Teleradiology has classically consisted of large private equity groups that have contracts with hospitals and radiology groups across the country. These groups employ radiologists to read the cases remotely (within the U.S. if performing final reads, outside of the U.S if performing preliminary reads).
Radiologists work from home and frequently have to be licensed in multiple states and credentialed at multiple hospitals. The radiologist also has to hold a state medical license in the state they are physically located.
Physicians are generally contractors (1099, self-employed) or direct employees (W-2). They earn income on an “eat what you kill” model based on production: the more relative value units (RVUs) you read, the more you can earn.
Earnings may be subject to the insurance of each patient, with CMS (Medicare and Medicaid) reimbursing at much lower rates than private insurance (i.e., you get paid less to read cases on patients with Medicare and Medicaid). It’s best to enter these jobs with realistic productivity expectations for yourself.
The combination of the COVID-19 pandemic and a national radiologist shortage (with probably ~50-75% more jobs available than applicants at the time of this writing) has encouraged multiple practices from all practice settings to create their own internal teleradiology opportunities with both employee and partnership track opportunities. This appears to be drastically altering the radiology job landscape.
Everyone in teleradiology is a diagnostic radiologist by default, reading studies of various subspecialties and imaging modalities they are comfortable with (x-ray, ultrasound, CT, MRI, nuclear medicine). What a radiologist reads can be based on personal preferences or on the needs of the group practice they join.
Locum tenens physicians are self-employed, independent contractors (1099). They typically sign temporary employment contracts with hospitals or physician groups in need. They frequently are connected via a third party company that focuses on placing locum tenens physicians as well as helping physicians and group practices secure long-term jobs.
Physicians that choose locum tenens work obtain state licenses in the states they work in and are credentialed at the hospitals or clinics they are affiliated with (this can be a painful process, but the third party locum tenens companies have staff that help with this – even so, it can be quite painful).
Locum tenens grants a lot of flexibility, allowing physicians to essentially work where (urban and rural areas), when, and for how long they want. This can be a great option for someone who wants to travel and see the country or test out some locations and group practices before becoming an employee or pre-partner.
Different types of medical practices vary widely but also have quite a bit in common.
Regardless of the practice setting you choose, you’ll find that nearly all physician practices need members for hospital committee work, medical directors (ambulatory clinics and hospitals alike), tumor board participation, quality committees, peer review committees, etc. There are almost always leadership and career development opportunities if that fits with your career goals.
While structures of different radiology group practices vary, you will still be doing what you (hopefully) love – practicing medicine and providing excellent medical care the only way you know how, reading radiology cases and/or performing interventional procedures. You’ll interact with other healthcare professionals, remain an expert imaging consultant, and add value to the field of medicine and your patients’ lives.
You will make a livable wage. There is some financial risk with a solo practice. Almost every radiology group practice consists of two or more physicians to disperse any financial risk and help cover overhead costs. Medical practices have variable salaries, but even the low end of the salary spectrum will allow for a very comfortable life.
Finding the right job can feel overwhelming at times, but you’re a doctor – overwhelmed is your middle name! Joking aside, hopefully you feel that you now have a basic understanding of the different types of medical practices that exist and the key differences between the major different practice settings. I hope this helps you feel a little more relaxed and knowledgeable during the job hunt process.
For jobs specifically in radiology, check out the American College of Radiology (ACR) Job Board, look to alumni from your residency or fellowship networks, and reach out to mentors within radiology. You’d be surprised how many physicians land jobs based on the network effect (vetting unknown radiologists is difficult).
Choosing a job or career should be a selfish choice. You want to set yourself up for success and achieve career satisfaction. In my opinion, the best way to do that is to put yourself in a group practice where you will thrive. Medical practices exist with nearly every possible permutation so find the one that best fits you.
Lastly, make sure you also take into account the desires and happiness of your family and friends, particularly your significant other and kids. You’ll find that the job of your dreams won’t necessarily overcome an unhappy spouse or family.