Douglas G. Burnette Jr., MD, CFP®

After over 30 years in the radiology trenches, I have raised the white flag and left the field of battle. Surprisingly, I have not missed it. More precisely, I haven’t missed the stress and pressure, the nights and weekends, or the sick-to-the-stomach feeling when I realized I missed something. The only thing I do miss is the people and, to them, I am and will always be grateful.

It is often said that you should be nice to the people you meet as you climb up the ladder of success because you may need them on your way down. Like the golden rule, I have always tried to treat others the way I wanted to be treated but, regrettably, I know that I haven’t always been successful and, for that, I sincerely apologize.

I want to thank my teachers, professors, fellow residents, partners, and all who have shared their knowledge and experience with me. I want to thank all the radiologic technologists who pointed out obvious misses as kindly as possible. I want to thank all the transcriptionists who caught my mistakes and put up with my absurdly long dictations until I matured in the profession and figured out what was important to say. I want to thank the ER docs who picked up the phone and gave me additional information or notified me of an error or omission in my reports in a timely and constructive way. I want to thank all the referring physicians who treated me like a valued colleague, consulted with me on their patients, and allowed me to feel that I was helping them care for their patients. I want to thank all the patients who have patiently endured my efforts to develop and improve my technical skills.[[{"type":"media","view_mode":"media_crop","fid":"34993","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_7430722541087","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3726","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right; height: 195px; width: 160px;","title":"Douglas G. Burnette","typeof":"foaf:Image"}}]]

I am especially grateful to my radiology partners who allowed me to transition gradually from my first career to my second by allowing me to work part time. As I have said before, retirement isn’t for sissies and requires careful planning. In the financial planning circles it is frequently said that people spend more time planning a single vacation than they do planning for their entire retirement. We advise our clients to “practice” retirement both in a budgetary sense and lifestyle sense before they actually retire so they can minimize some of the rude surprises that await.

Retirement is not the never-ending weekend of relaxation and fun that many imagine. Everyone should plan for their retirement and develop a purpose and structure for this final phase of their lives. For many physicians, their identity is closely tied to the profession of medicine and the loss of their work identity is extremely difficult. In my case, I rarely used my title of doctor outside the hospital or felt my identity was closely related to my profession. I found it quite humorous that at my retirement party many of our neighbors and acquaintances were surprised to find out that I was a radiologist.

Radiology has been a great profession. It has provided well for me and my family. I am grateful that I had the opportunity to help my fellow man. I believe I did more good than harm. Radiology has undergone tremendous change during my career and I will be a very interested observer in how radiology and medicine continue to change in the coming years. Farewell and thank you, radiology. I wish you well.

Articles

Farewell, Radiology

“May you live in interesting times.”- Old Chinese curse

I always marveled at the changes that my grandmother witnessed in her lifetime. She was born the year the Wright brothers made the first powered flight, rode in horse-drawn buggies, lived through two hot World Wars and one cold one, saw the dawn of the atomic age, and lived to see men walk on the moon.

Likewise, my career in radiology has spanned a time of great change-very interesting times indeed. I have seen red goggles worn prior to fluoroscopy, great barrels of barium sulfate to be mixed into oral and rectal preparations, rectilinear nuclear medicine cameras, B-mode sonography, handmade angiography catheters, IV cholangiography, water bag head CT requiring several minutes per slice, and MRI when it was called Zeugmatography and thought unlikely to ever be clinically useful. I have used mirror optic fluoroscopy. I have performed Pantopaque myelograms, dacrocystograms, a pneumoencephalogram, marathon lymphangiograms, and had fluoroscopy schedules with over 20 patients in a morning.

I experienced the halcyon days of radiology income, the “Golden Years.” In those days, the numbers and types of new procedures were years ahead of the CPT codes, and Medicare reimbursement was a good thing. In those days, not everyone wanted a piece of our turf and there wasn’t all that much to do (or could be done) on call. Weekends consisted of a few hours on Saturday and Sunday and call backs were relatively infrequent.

I have witnessed tremendous change in the landscape that is medicine and radiology. I have experienced the explosion in the numbers of images, volume of studies, speed of performing studies, and increased stress that is part of the job of being a radiologist today. I have experienced the transitions from analog to digital imaging, xero to digital mammography, transcription by humans to computerized speech recognition, the change from a relatively active, highly interactive day to an isolated and sedentary workday, the depersonalization of medicine and disappearance of useful medical information and relevance, the ratcheting downwards of reimbursements, and the annexation of our turf by other specialties.[[{"type":"media","view_mode":"media_crop","fid":"32531","attributes":{"alt":"Game over","class":"media-image media-image-right","id":"media_crop_8908078475103","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3434","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 200px; width: 200px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"Â©wongstock/Shutterstock.com","typeof":"foaf:Image"}}]]

This change has been painful, as most change is, and it seems to be accelerating at breakneck speed. Health care is under scrutiny from all sides and the government is taking it over (or has taken it over depending on your point of view). Our specialty is at particular risk because we have never really been understood or appreciated by patients or other physicians. It is at risk because we don’t have an effective voice and because we don’t appear to work very hard for what we earn. In fact, we are rarely “seen” working.

Radiology will survive, but will probably not be recognizable by those of my generation. Radiologists will likely be employed by hospitals or large mega-groups. They will be shift workers processing large volumes of digital information with little or no access to the patient or the referring physician. Computer generated studies such as bone densitometry will bypass us entirely. Many studies such as ultrasound will be reported directly by the technologist. Vascular access and dialysis maintenance procedures will be performed by non-physician personnel, as will the few fluoroscopic procedures still being performed.

This evolution will be painful but there will eventually be a generation of radiologists who have none of my memories. They will have no idea why reporting an urgent study would be called a “wet reading” or that there was a time when we were the doctor’s doctor and our expertise spanned all specialties. This generation of radiologist will be making more money than they ever have before and will not know there was a time when radiologists earned far more. They will be content. The interesting times we are living in will have been forgotten.

This, Too, Will Be Forgotten

I have a good friend who has a theory that your various body parts have a limited number of uses, thus explaining the proliferation in joint replacements and “little blue pills.” I wonder if the same is true for the number of decisions a person can make in a career or the number of radiology reports one can read.

When I started out in radiology, the maximum number of images in a study was in the tens. Now, with CT and MR, the maximum number of images is in the hundreds and even thousands. The digitization of radiology has played a large role in this. In the days of matrix cameras and manually processed image cassettes, the fact that the techs had to load and unload matrix camera cassettes and insert the films in a processor was probably some deterrent to large studies, and I remember complaining to an ultrasound technologist that she wasn’t giving me enough images on the studies she was submitting back in those days. Nowadays, I feel like I’m viewing an ultrasound video frame by frame with image counts sometimes approaching a hundred. I know, be careful what you wish for.

At the end of a long day of reading imaging studies, I frequently feel like I can’t make any more decisions (much to my wife’s chagrin when she wants to know what I want for dinner). I want to believe that the quality of my decisions is as good as ever, but I am haunted by a statement I made half a dozen years ago when I made the decision to go part time. When asked how long I intended to practice part time, I said I didn’t know but believed once you cut back, the clock starts ticking and one’s ability begins to atrophy.[[{"type":"media","view_mode":"media_crop","fid":"31533","attributes":{"alt":"blue pills","class":"media-image media-image-right","id":"media_crop_7757579860016","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3329","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 107px; width: 160px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":" ","typeof":"foaf:Image"}}]]

It is true that my sense of enjoyment practicing radiology was revived temporarily by being able to choose when and how often I worked, but the decreasing frequency of call and weekends made them even more unpleasant when they occurred as the months went by. I am sure that some groups have discovered ways of minimizing stress and increasing individual longevity. There are, after all, radiologists practicing into their 70s and I know of one in his mid-80s.

Most groups I have worked in believe that everyone has to pull their weight, and that means call and weekends. Perhaps implementing a shift system that limits the number of hours worked similar to airline pilots and truck drivers will prolong careers in the future. Perhaps someone will invent “a little blue pill” for radiologists. What do you think?

Does Radiology Need a Little Blue Pill?

I have a client who is in Federal law enforcement and is faced with mandatory retirement at age 57. To be forced to retire at a relatively young age is potentially traumatic and definitely calls for careful and thorough planning, which is why he sought us out. He has mixed feelings about his retirement and feels that he still has a lot to offer. He is not on the front lines anymore and the reasons for retiring him from his desk job seem a bit arbitrary.

Upon further investigation, he is not alone. A friend of mine is an air traffic controller and told me that he, too, has a mandatory retirement age that is fast approaching. Based on my own 30 year experience in radiology, I asked if he thought it was a waste of talent and experience to force him to retire. He looked at me with sad eyes and said, “It’s a young man’s game.”

I have been most fortunate that my former radiology group allowed me to retire at age 59 and continue to work for them on a part-time basis for the last five and a half years. That allowed me to transition from radiology to financial planning. It has been good for me in many ways but it has also been good for the group. My availability to work a day here or a day there, swap weekends or give them some extra vacation has been much appreciated. Before I went part-time, there was very limited flexibility in the work schedule.

I remember the night I told the group of my intentions. They asked me how long I planned to work part-time. Other partners had retired and started to work part-time but quickly quit and retired full-time. Acknowledging the philosophy of “If you don’t use it, you lose it,” I prophetically stated that once someone goes part-time, the clock starts ticking and the skills start atrophying. I didn’t know how long I would last.

Last month I stopped working weekends. Words cannot express how good that felt. Our weekend call has become onerous and exhausting. We typically take call from 4:30 PM Friday to 7 AM Monday with an assist from an internal night hawk. Weekend call is sandwiched between two full work weeks. We don’t get days or afternoons off. The volume of work on weekends has skyrocketed. One of the two weekend rotations covers three different hospitals. Usually at least one of the hospitals is really busy and when all three are busy and you get called out to do a hospital procedure or have to stand by for a contrast injection at an imaging center, things get outright frantic.

So there isn’t a mandatory retirement age for radiologists, but maybe there should be. It is, after all, a young man’s game. Unfortunately, even the young radiologists I know are feeling the pressure.

Other industries have mandatory retirement ages, should radiology?

Radiology: It’s a Young Man’s Game

When the Russians got the bomb, the United States needed to develop a nuclear deterrent policy for our military. Thanks to captured German scientists, the United States and the Soviet Union developed intercontinental ballistic missiles capable of carrying nuclear weapons and death on an unimaginable scale to any point on the Earth. It was a mad time, in the sense of the doctrine of “Mutually Assured Destruction.” Massive destruction is something government is good at.

At the same time American technology created a super stealthy delivery system in the form of nuclear submarines. In fact, the silent service was so capable; no other system of deterrence was  needed. But that is not how the military, or the government, operates. The Army and Air Force couldn’t tolerate the Navy being the only service with nukes. No, sir.

Thus the tri-lateral, deterrent strategy was born and the arms race begun. In truth, our military was competing in an arms race amongst itself as much as with the Russians. This is the way our military and our government thinks. For example, each branch of service has its own medical corps with triplication of every aspect of the military health care system save one - the military medical school, the Uniformed Services University of Health Sciences or USUHS (or “Useless” as we called it at Bethesda). USUHS did show that collaboration and pooling of resources in the military was possible and led to speculation on whether there would ever be a single military medical corps or “purple” suit (combining all the colors of the uniforms). Don’t hold your breath.

So to government minds the idea of another separate health care delivery system for veterans and their families, aka the VA, makes perfect sense. There is the added bonus of members of Congress being able to bring home the pork to their districts in the form of VA hospitals and jobs. Never mind that the hospitals may be inconveniently located, inefficient, riddled by bureaucratic incompetence and, on occasion, fraudulent administration as has been documented in the media recently.[[{"type":"media","view_mode":"media_crop","fid":"27921","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_1017243771348","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2788","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"line-height: 1.538em; height: 227px; width: 166px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":" ","typeof":"foaf:Image"}}]]

Considering the cost of all this duplication of health care systems and the innate inefficiency and waste of the government as it attempts to do anything, would it not make more sense to do away with the VA and reimburse local hospitals for caring for our veterans?  Our veterans deserve the best care available as a down payment on a debt that can never be fully repaid. Having worked in a VA, I’m not sure that that is currently the case. In the same sense, paying for military medical students to attend existing medical schools would undoubtedly cost the taxpayer less. I’m pretty sure “sense” and “government” should never be used in the same sentence.

With government running amuck as it currently appears to be, I suppose we should be grateful that there isn’t a VA Health System for each branch of the service. I hope no one in government reads this because I don’t want to give them any ideas.

Veterans aren’t receiving the care they deserve, says this radiologist.

Nuclear Deterrence and the VA

As I stroll through the area where the techs and transporters hang out between patients, I am struck by the contemplative, almost prayerful way everyone is gazing at their hands, or more precisely, their smart phones. We hear more and more often about children losing the ability to interact with others because of their fixation on digital devices. It can be hard to pry a grandchild from his electronic tablet to go outside and play. I frequently find myself losing out to streaming movies, cartoons or some online game in this regard.

Indeed, as a society we are becoming more comfortable with texting or emailing than with person to person communication. Most of us have had some unpleasant experiences with the lack of a “tone font” or an unintended group message. Nowadays, I am trying to pick up the phone and communicate directly if I am not able to communicate face-to-face. It leads to less mistakes and better understanding.[[{"type":"media","view_mode":"media_crop","fid":"27095","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_2906310804081","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2603","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 100px; width: 150px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"","typeof":"foaf:Image"}}]]

As radiologists we have become masters (or possibly slaves) of the digital world. Our work can be done from almost anywhere. There are weekends on call when I never set foot in the hospital. Unless there is a procedure, I don’t need to. My speech recognition generated reports are so formatted and filled with auto-texts that they seem totally machine generated with no personality or style. The need to capture every observation in an obstetrical ultrasound in order to bill for a complete rather than limited examination has lead to a standard plug-in report that could come from a technologist generating a standard report from their findings and measurements or a robot.

Radiologists along with the rest of society are becoming digitally detached and the more detached we are, the harder it is to assert our value. Our virtual omnipresence and digital efficiency may have sown the seeds of our destruction. Have you noticed how often websites offer live chats lately? I believe that while this is a very efficient way to communicate, it also removes the barriers and stigma of language and ethnicity from the exchange of information. The frustration of dealing with someone in a phone bank in India is gone. It will be just that easy to replace us someday.

What do we offer to counter this? Radiology services are being effectively commoditized. I admire the efforts to educate the public and put our best face forward to patients and referring physicians. Unfortunately, in today’s busy practice it is rarely practical to speak directly with patients on a routine basis. I have found that my pace has gradually increased to cope with peak work flow times and I am unable to slow the pace even when there is a lull in the action.

Over the years it has been difficult to earn the respect of my medical colleagues even to the extent on occasion of having to assert that I am a real doctor not a technologist. I suspect that as medicine evolves or devolves (depending on your point of view) we may, indeed, become essentially technologists. One day we may even become an app on a digital device - the ultimate in digital detachment.

Will technology make the radiologist obsolete one day?

Digital Detachment and the Radiologist

When I was a brand new, private practice radiologist in West Virginia, one of the older radiologists would say to me, “Let’s go get a coke.” We would then proceed to the cafeteria and he would enlighten me about a great many things including life, marriage, hospital politics, investing, golf, philosophy and the practice of radiology over a carbonated beverage.

One of the first pieces of wisdom he imparted was that prior to this point in my life, everything had been temporary - college: 4 years, medical school: 4 years, residency: 3 years, fellowship: 2 years. From this point in time there were going to be no more “calendar reprieves” for me. I had to accept that I was facing a long term situation and commitment and make the appropriate mental adjustments.

I didn’t fully appreciate the value of the wisdom he was imparting at the time but realize now how important it was to have a mentor. During all those years of medical education, residency and fellowship, there was no education on practical matters such as contract negotiation, practice management, business accounting, life and disability insurance, tax planning and investing.

In all but one of the groups I have been in over the last 30 years, the management of retirement funds was left up to each individual participant with no direction or assistance. The one group that did manage the retirement fund gave me a list of mutual funds to choose from but again no real direction. 

Contrary to what seems to be the prevailing opinion amongst most physicians, an in-depth knowledge of anatomy and physiology and an above average level of intelligence do not automatically confer the possessor of a medical school degree with the ability to invest retirement funds wisely.

When I reflect on how important saving for retirement is, I wonder why I never took it more seriously or sought professional advice until fairly late in the process. Perhaps this was partly due to the confusion over what a financial advisor is and what they do. It seems everyone who has anything to do with my money including insurance salespeople, bankers, stock brokers and so on, call themselves “financial advisors.”

It took me a while to realize that the wirehouse brokers weren’t really advising me so much as selling me something to make a commission. Perhaps it was because I was doing what I saw all my other colleagues doing.

When I finally decided to take action, I began by reading “The Millionaire Next Door” by Thomas J. Stanley, PhD and William D. Danko, PhD, reasoning that if I wanted to accumulate wealth, I should begin by studying people who already had. One piece of advice stood out, find the best financial planner you can afford and hire them. I was fortunate to find such an advisor and became so interested in the process that I decided that I wanted to help others plan for retirement, too.

One of my financial coaches observed that as a physician myself, physicians were my natural niche. He obviously did not know much about radiology. After 30 years working as a radiologist, I wasn’t so sure I wanted to work with physicians and their money. Nonetheless, I have made a sincere effort to help physicians review and improve their retirement plans.

I am especially committed to helping the “newbies” in radiology. It is hard enough for them to make the transition from training to private practice without having to earn a degree in finance. Our young colleagues need mentors. There is no reason for them to have to reinvent the wheel and we have a wealth of experience to share with them. I know I am grateful to my mentor. Thanks, Mack.

Mentors need to step in for what medical school doesn’t teach radiologists, like preparing for retirement.

Radiologists Need Financial Mentors

Have you noticed that our work as radiologists seems to be getting busier at night and on weekends? The urgency and pressure clearly increases. In our practice, there is general agreement that there is a mismatch between our staffing and the workload. We put radiologists in work slots based on our desire to work a “normal” daytime shift, like bankers and postal workers. It seems we are relatively overstaffed during the day and understaffed at night and on weekends based on the volume of work.

We cover several hospitals and imaging centers and the workload varies by location and time of year. This is further complicated by the fact that certain radiologists can only cover certain slots. One hospital is busier than the others. In theory, everyone is supposed to pitch in remotely and if they are caught up on their own work list they are supposed to help out the guys who aren’t. In practice, this turns out to be highly dependent on the individual radiologist. Some help out more than others.

Our group still considers call to be an extension of the workday. The radiologist on weeknight call has already worked a full day and weekend call is an add-on to a regular work week. Fortunately, an in-house “nighthawk” service was created and a normal call weekday is only about 13 hours long and weekends 14 hours, although you are actually on call all night. I don’t know about you, but after 12 or 13 hours of staring at a monitor, I’m just not as sharp as I was when I started. I’m also not as sharp on Sunday evening as I am Monday morning either. Many job classifications including airline pilots and long haul truckers have limits set for how long they are allowed to work per day. Perhaps radiologists should have a maximum number of hours to work per day or week also.

Some groups have addressed this issue by staggering the shifts that radiologists work, realizing that there is no real end to the day and ferrying in fresh bodies from the bench can lessen the strain imposed by long workdays. Having worked in a practice where the night shift was rotated amongst all the radiologists, it usually took me at least a week to recover from working a week of nights. The normal human diurnal cycle means that most of us will not be as effective working off hour shifts, especially long off hour shifts.

Some of the teleradiology companies had the smart idea of employing people who lived around the world so they could work a “normal” daytime shift and cover the night time shift half a world away. This tends to be a credentialing nightmare and leads to the further commoditization of our specialty, although the thought of living in Australia or Switzerland definitely intrigues me.

It seems that the only way to work a reasonable number of hours and still get the work done is to work shifts similar to Emergency Room physicians. Given the specialization of our imaging services this would be a scheduling nightmare and bound to lead to disgruntlement in the ranks. In my crystal ball I see lines of radiologists slowly trudging into and out of a drab radiology factory around the clock much like the opening scene of the Tom Hanks movie “Joe Versus the Volcano.” Anyone have a more cheerful suggestion?

Long hours can decrease a radiologist’s productivity, how should we handle the increasing workload?

Should Radiologists Work in Shifts?

I recently spoke with a physician who is about to retire and was surprised to hear him say, “Well, since I am retiring soon, I guess I need to find a hobby.” With all the unhappiness in medicine these days and the threats and/or dreams of retirement that are so frequently heard in the doctor’s lounge, I am amazed at how little actual planning for retirement is being done. It has been said that the average American spends more time planning for a vacation than for retirement. Doctors are probably much worse.

There is a retirement crisis in this country-both in the funding of retirement and the detailed planning of what that retirement will look like. The old scenario of working for the same company until one’s mid-60’s, receiving a gold watch, a pat on the back and heading off to the fishing hole or rocking chair has long ago become passÃ©. This is especially true for physicians. Physicians start their careers, on average, at least a decade later than most workers, frequently with substantial debt and often a limited career span, especially for some of the surgical specialties. Radiologists are fortunate to be able to have long careers if they choose. I know a radiologist in his mid-80’s who still actively practices in the community hospital setting.[[{"type":"media","view_mode":"media_crop","fid":"24722","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_2273029034168","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2173","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 172px; width: 250px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":" ","typeof":"foaf:Image"}}]]

With the possible exception of my octogenaradiologist friend, most people live as long or longer in retirement as their active work years, so it can be a tremendous challenge to properly fund that retirement. Physicians must earn and save enough money during their working years to sustain them throughout their retirement. We tell our retired clients that they need to think of their retirement savings as their new employer. By employing a saving-first mentality and following a prudent investment philosophy, the accumulation of a retirement nest egg can be relatively straightforward, however. The real challenge starts when actual retirement begins.

Most people have no idea what it will cost them to live in retirement. So long as they are working and there isn’t too much month at the end of the money, life lurches along in a more or less comfortable fashion. When the paycheck stops and you have to start living on a budget, reality rears its ugly head.

It used to be said that people should plan on living on about 70 percent of what it cost them to live pre-retirement. Now, needing more than 100 percent of that number is closer to the mark. People in retirement are healthier, living longer, more active, more able and willing to travel, and frequently have more financial responsibilities, including aging parents and children and grandchildren in need of assistance. We recommend that our clients “practice” retirement by living on their retirement budget for the year before they actually retire.

There are other important aspects like spending more time with a spouse who is used to you working all the time. This is frequently a painful adjustment. Many physicians feel defined by their profession. The loss of status and self-esteem associated with physician retirement is not to be underestimated. What will your days look like after retirement? Will you volunteer, teach, travel, start another career? An excellent book to help you explore this topic is 

 by Jeri Sedlar and Rick Miners. It has had a profound effect on my life.

I wished my friend luck on finding a hobby to fill his time and the void in his life when he leaves his long career in medicine. He is in for some real challenges. Retirement isn’t for sissies, you know.

Radiologists might find that planning for and enjoying retirement is more challenging than expected.

Retirement Isn’t for Sissies

At a meeting of fellow financial advisors, a speaker recommended a book entitled “Checklist Manifesto” by Atul Gawande. Since this book was recommended in conjunction with my financial advisory practice, I was surprised to learn that Gawande is a surgeon and actually wrote the book as the result of a World Health Organization project to reduce operative mortality. Another 

 in this space by Dr. Woodcock has already extolled the virtues of utilizing checklists in radiology.

Dr. Gawande gave many examples of how checklists can make complex processes safer and more consistent. One such example concerned building huge sky scrapers. There was a time in the not too distant past when a master builder could supervise the building of structures from concept to final construction, providing knowledgeable oversight throughout each phase of the building process. Because of the complexity of modern buildings, such a “master” builder is no longer possible and each and every aspect of building requires its own expert builder and exhaustive checklists and timetables to ensure a successful completion of the project.

Dr. Gawande observes that modern medicine is still practiced using the “master builder” model. Even though most physicians don’t have a detailed knowledge of medical imaging, with its indications and limitations, they order large batteries of imaging studies, without apparent concern for imaging efficiency or appropriateness. This approach is counterintuitive at the very least and downright dangerous on occasion. It definitely seems to be at odds with the concepts of “accountability” and “medical necessity.”

Back in the early 1980s during my pediatric radiology fellowship at the Children’s National Medical Center in Washington, D.C., I enjoyed the experience of working with and learning from some excellent physicians, both radiologists and pediatric specialists. Ultrasound, CT and angiography were fairly new in pediatric radiology. For instance, I remember forming catheters over steam because there were no preformed angiographic catheters. I also remember receiving radiology requests stating “Two-year-old male with abdominal mass. Please evaluate.” The radiology residents, fellows and attendings would then put our heads together and decide on the optimum imaging workup to reach an imaging diagnosis for this particular patient. Diagnoses were frequently made within hours. There was never any concern that we were self-referring or churning studies. Problem presented. Appropriate imaging performed. Problem solved.

Such a rational approach to diagnostic imaging is unimaginable in today’s medical environment. In fact, current electronic order entry systems with extensive imaging menus being input by ward clerks or nurses makes selection of the most appropriate imaging studies highly unlikely. While a few physicians take the time to discuss their difficult patients with us and plan a logical diagnostic imaging sequence, most don’t have the time or inclination, or only call to discuss the results of the studies they have already ordered.

There are many times when I just shake my head and realize that instead of being a “master builder” or even someone at the table with input on the project, I am actually more like a brick mason, laying brick after brick from a pile that somebody else has stacked for me.

There was a time when radiologists only had to worry about determining the appropriate study and diagnosing the patient. 