Why Dutifully Waiting in Line is No Longer an Option for Advancement in Radiology

I am told that some teleradiologists develop regrets about moving to fully remote work. It makes sense to me even if I don’t share the sentiment. Different strokes for different folks as the saying goes.

If you told me I had to come up with a regret, a contender would be that I have pretty much no idea what is on the mind of newcomers to the field. I communicate with peers, of course, but none of my work involves residents or freshly graduated attendings. I dabble in radiology social media, but my chosen platforms (Facebook, X) don’t tend to be stomping grounds for the younger folks.

However, recollection from that stage of my career has not faded. We absorbed the view of our mentors, which was how health care traditionally went. Apply yourself, get a good job, and work your way up through the ranks. In the hospital setting, you will reasonably hope to earn recognition, perhaps becoming a section head or department chair. In outpatient imaging, demonstrating your value could gain you partnership.

That is a continuation of the path that one typically follows to become a radiologist in the first place. You rise through the ranks of college, med school and residency with a reward at the end of each phase. With each graduation, there is greater responsibility and perks to go with it.

It is reassuringly orderly. Not unlike getting in line and waiting your turn (to be served at a counter, to board a plane, whatever), you reliably advance with little doubt of achieving whatever outcome the queue promises. People who got there ahead of you reach the goal first, and you take it as a given that you will get yours before those arriving after you do.

At the time of my residency, however, some of us heard rumblings that the way of things might be changing in radiology as well as the rest of health care. Rumors percolated about rads being passed over for promotion in hospitals or unexpectedly denied partnership after dutifully completing the “track” of years that were supposed to lead to such elevation.

It was easy to dismiss those as rare outliers or stories told by bad eggs who had misbehaved and thus disqualified themselves from the normal career-advancement path. This was partially the case because we heard much more frequently about rads who did get what they were supposed to after they had waited in line but also because it was unpleasant to think that we could do everything right and, unlike previous generations of radiologists, have the rug pulled out from under us.

Fast-forward a few years and many of us found that the rumors were far from false. The line was no longer a reliable thing. You could get up to the front only to have the individual at the counter turn you away empty-handed. We soul searched to varying degrees, trying to figure out what we had done wrong to deserve this. However, soon after comparing notes with each other, we saw that the fault, while it might not be in the stars, was definitely not in ourselves.

It wasn’t always a matter of bad behavior on the part of the hospitals and rad groups. Reimbursements were dropping, overhead was climbing and with thinning margins, the promises of yesteryear couldn’t always be lived up to.

True, the execution was often poor. You might imagine that a valued rad would be sat down sometime before his or her partnership track was at its end for a frank discussion: Hey, just so you know, things are changing, and we want to be upfront about this rather than springing it on you at the last minute. Let’s talk about how we can retrench things in a way that works for everyone.

Of course, such conversations are awkward, and one never knows how the partner candidate might react. It’s easier for such talks not to occur just out of benign neglect. One needn’t blame calculated malfeasance although the latter isn’t exactly rare.

More blatantly, a lot of rads were regarded as disposable commodities. Partners sold out to private equity, got their golden parachutes, and whoever wasn’t partner yet suddenly had a new boss with new rules. Hospitals cut loose their rad departments in exchange for other coverage that produced prettier spreadsheets (or promised to). My residency showed me an early example. Halfway through my training, a local private practice suddenly took everything over.

People react differently to sea changes like this but in venues with an emphasis on tradition (like health care), there tends to be a bias towards clinging to the old ways even if they aren’t working so well anymore. A lot of rads, especially those who had successfully waited in line themselves, were of the mind that others should do the same: It is still the “right thing” to get in line and wait your turn. If you did your due diligence before signing a contract, it should work out for you.

For younger rads facing the rising probability of wasting years in partnership tracks that would yield no partnership, that did not sound so good nor was the notion of taking pure-employment jobs, hitting compensation-ceilings, and then facing ever increasing demands of working hours, productivity quotas, etc.

An increasingly common behavioral response was, essentially, to stop waiting in line. Give up the ghost on partnership or any other sort of hierarchical promotion and just go for the healthiest paycheck and/or the best lifestyle. If, one day, job A started demanding more or paying less than you knew you could get at job B, you switched. Many rads moved from traditional employment to working as independent contractors if not full-on locums.

The traditionalists did not like that. For some, because the positions they had attained depended on future generations of rads continuing to wait in line behind them (a cynic might liken it to a pyramid scheme). If, as a partner, you count on future would-be partners coming to work for you as associates for a cut rate, and that pool of labor dries up, your operation might lose viability.

For others, it was a more genuine, less self-interested matter. They still believed in the older way of things. Waiting in line and rising through the ranks worked for a long time. If that system was failing because of overbearing government and intrusive corporate behavior, the need for change resided with those outside influences. Rads behaving in more mercenary “every man for him- or herself” ways was adding another wrong, which would never make things right.