What It Means To Be A Radiologist: A Guide For Medical Students!

Dr. Ravi Ramakantan sir, one of the greatest Indian radiologists and a legendary teacher (former Head of Department Radiology, KEM Hospital Mumbai and Kokilaben Dhirubhai Ambani Hospital Mumbai), does this interesting exercise in his radiology lectures in front of a packed audience. He asks everyone in the audience to close their eyes, be completely honest with themselves and raise their hands if the answer is yes:

Before selecting radiology as a career, did you know 100% what Radiology is all about?

In an audience of hundreds, hardly a few hands go up. He would do another exercise for every new batch of first-year radiology residents in his department. He would ask each one of them individually:

Why did you select Radiology as a career?

The answers would range from thoughtful silence to “I like photography”, “I want a chill life and earn big bucks” to “I would like to stay in touch with all organ systems and branches”. 

It is NEET-PG counseling time again and I get messages and calls from many places in India every year asking about radiology as a career choice. All the aspirants’ questions can be distilled into two broad ones:

1. Whether I should choose Radiology vs XYZ branch?

2. If opting for Radiology, what is the preference order for colleges?

For the latter, you can read our elaborate article: Radiology NEET PG guide – How to select THE best college for post-graduation in Radiology (includes personal insights)!

Let us try to answer the first one.

Unfortunately, we are not exposed to radiology during our MBBS days so it is difficult for someone to be passionate about radiology in our undergraduate (UG) period unless they have a relative / close friend who is a radiologist and they know in detail what working in radiology entails. So I will try to give an idea of what radiology is through this write-up, from which Pre-PG aspirants will get a general concept of radiology as a career. One of the best things you can do is to spend 2-3 days in a high-volume hospital’s radiology department to get an idea regarding the actual work in the field.

Before we begin it is important to understand something which may not be apparent in UG days or post-internship. No branch is better or worse than another. It is a completely individual decision based on your liking, goals in life, and long-term plans. There is no right or wrong answer, it is about selecting the branch which is MOST SUITABLE FOR YOU. 

This topic can be approached in a question and answer format and I will try to cover the questions I am commonly asked by aspirants, and maybe as we discuss along the way we will get an idea of what it means to be a radiologist in the 21st century.

Disclaimer: This article is written with Indian medical students and the Indian radiology scenario in mind. It may not apply to radiology practice in other countries, but the guiding principle would be similar.

1. What is Radiology?

Everything in this universe is made up of 2 things: either matter or energy. Radiology is the medical science of using energy to look at matter. Other terms used interchangeably are “Radiodiagnosis”, “diagnostic imaging”, ‘medical imaging’ or ‘imageology’. I disagree with the term ‘Radiodiagnosis’ used in India, as a musculoskeletal interventional radiologist myself I do image-guided therapies as well and not just diagnosis, and the same holds true for all interventional radiologists.

Radiologists use X-rays, Ultrasonography (USG), Fluoroscopy, CT, and MRI scans to diagnose patients’ diseases. Interventional radiologists use USG, CT, Fluoroscopy and even MRI scans to perform image-guided diagnostic and therapeutic procedures (called interventions). In India PET scans, SPECT scans, and scintigraphy are the domain of MD / DNB Nuclear Medicine. However, a radiologist with adequate exposure can interpret PET-CT scans.

2. How challenging is Radiology?

Radiologists diagnose scans sent to us by doctors from at least 37 different MD, MS, DM, and MCh specialist and super-specialist branches, many of whom are further fellowship-trained highly specialized doctors, eg. Cardiologists who are arrhythmia specialists, Neurosurgeons who do only skull base and craniovertebral junction surgeries, Orthopedic Oncosurgeons who treat bone and soft tissue tumors, etc. It is extremely challenging to continuously remain updated with not just the imaging but also the clinical and therapeutic aspects of all these branches which radiologists need to do, and all of them have recent advances happening at a rapid pace. It is extremely difficult to be a good radiologist, however, it is easy to be a mediocre radiologist (this would hold true for all medical fields).

At the same time, it is extremely rewarding to make a diagnosis for a patient which no one else could have, which results in saving the patient’s life, changing their treatment course, or making their life better. Like picking a cervical rib in an upper limb CT angiography as the cause for the patient’s upper limb arterial thrombosis (thoracic outlet syndrome) and completely changing the management, precisely diagnosing an elite athlete’s shoulder injury on an MRI scan helping them to receive the correct treatment and gain rapid recovery, or picking an early renal cell carcinoma in the lower sections of a CT thorax done for COVID-19 leading to the patient getting cured completely by a nephrectomy: good radiologists add value to patient care day in and day out with what they do. Radiologists are the Batman of medicine: almost no one knows what they do or who they are but what they do is extremely crucial and may be life-saving. We also may not get credit from patients for these life-saving diagnoses but that is OK, we joined radiology knowing fully well that this would be a part of the job. Giving your best without expecting anything in return is a reward in itself.

3. Is Radiology a light branch?

No, this is a common misconception. Any branch can be workload light or heavy depending on your working conditions. The hours in radiology do not differ from other branches. The nature of work for diagnostic radiologists (CT and MRI) does involve sitting in AC rooms in front of workstations and diagnosing scans however that can have its own side effects (like chronic eye strain). Many sonologists get chronic musculoskeletal disorders of their upper limb and shoulder from doing constant ultrasound scans.¹ Also in order to really be a good radiologist you need to remain constantly updated with all medical subspecialties which involves constant reading and also discussing scans with the referring surgeon or physician after work hours.

Radiology is not meant to be practiced by locking yourself in a dark room from morning till night reporting scans on a workstation. Real radiology is practiced by discussing scans with the referring docs, developing a good rapport with them, learning about other branches, and getting to understand what exactly each doctor wants in the report which will aid in treatment planning.

It is also important to always remember there is a patient behind the scan you are reporting, and you are not just diagnosing images.

Radiology residents and early-career radiologists would also do well to report as many complicated cases as possible. Don’t run away from reporting complicated cases. Given a choice between reporting a normal CT brain or CT thorax versus reporting a challenging CT of an extensive head-neck malignancy, some weird multi-system syndrome, or a complicated MRCP, always choose the latter ones. The more difficult the better, and try to be the one in your department or practice who always picks the complicated scans for reporting. It may take a lot of time, effort, and reading initially but it will be worth it in the long run.

4. Do radiologists earn a lot of money?

Yes and no. There is no straightforward answer and doctors from all branches earn on a spectrum. There are doctors who earn 2 standard deviations above and 2 standard deviations below most colleagues in their field. When looking only at MD and MS branches, yes salaried radiologists on average earn more than other branches especially in tier 2 and 3 cities. However, DM and MCh superspecialist branches on average would earn more than a salaried general radiologist (nonspecialized) in the same city. At the same time entrepreneur radiologists do extremely well monetarily and you will see the highly successful ones driving Jaguars, Bentleys, and sports cars. However, radiology is a very capital-intensive field requiring high CapEx for private standalone practice and may be impossible without having access to large funds in crores or establishing a practice in partnership with other like-minded radiologists. Radiologists who have relocated outside India on average earn much more than their counterparts in India, especially those in North America, Australia, and Gulf countries.

We practice medicine in the real world and doctors are not saints or hermits who should be expected to work without adequate monetary compensation after spending 10 plus years of their life studying and pursuing professional excellence. Medicine is not practiced in a vacuum, there are social and economic factors for the doctors and patients as well. A doctor can be rich and at the same time be caring for his / her patients. In this scenario and with the rising violence against doctors in India, it makes complete sense if a medical intern wants to choose radiology and live a relatively hassle-free life. As long as you are clear about your reasons why you are selecting a particular postgraduate branch there is no need to feel guilty about the decision. It is absolutely fine to choose radiology with the aim of living a well-balanced life and earning good money, however, one must not forget to become a good radiologist first by working hard, and always keeping the well-being of patients front and center. Excellence should be the primary aim, the money will follow.

5. What is Interventional Radiology?

Interventional Radiology (IR) is a specialized branch of radiology involving the treatment of patients using minimally invasive image-guided procedures. IR is as cutting edge as modern medicine can get when it comes to minimally invasive treatments for a variety of diseases. Interventional radiologists use USG, CT, fluoroscopy, and even MRI as imaging guidance tools to perform highly precise and targeted therapeutic procedures, all mostly through a pinhole incision. These days almost all general radiologists who are passing MD / DNB perform diagnostic interventions such as USG and CT guided biopsies, FNACs, aspirations, pigtail catheter insertion, etc.

Read our detailed post about IR: Interventional Radiology – All Your Questions Answered!

Despite the large variety of life-saving and completely life-changing procedures done by interventional radiologists, there is a striking lack of awareness regarding the field among the general public. Radiology and especially IR have an image problem. Even among medical students, the awareness is less, mostly because of a lack of exposure to the field during MBBS days. However, a recent study published in the Indian Journal of Radiology and Imaging (IJRI) shows a majority of medical students would consider it as a career choice provided awareness was created among them regarding IR.²

Interventional Radiology has now become further specialized into various branches, all having considerable overlap:

• Vascular Interventional Radiology : vascular procedures like peripheral and abdominal angioplasties, stenting, aneurysm coiling, endovenous laser ablation for varicose veins, uterine artery embolization, bronchial artery embolization, thrombolysis, IVC filter insertion, transjugular intrahepatic porto-systemic shunt (TIPS), etc.
• Interventional Neuro-Radiology: cerebral aneurysm coiling, arterial thrombolysis for stroke, embolization for certain brain tumors, arterio-venous malformations, arterio-venous fistulas, ophthalmic artery chemo-infusion for retinoblastoma, etc.
• Interventional Onco-Radiology: tumor ablations (radiofrequency ablation / RFA, cryoablation, microwave ablation) for the liver, kidney, lung, bone, trans-arterial chemoembolization (TACE), trans-arterial radioembolization (TARE), etc.
• Gastro-hepatic Interventional Radiology: percutaneous trans-hepatic biliary drainage (PTBD), TIPS, ablations, TACE, TARE for liver tumors, etc.
• Musculoskeletal Interventional Radiology: intra-articular, muscle, tendon and nerve injections, spinal and nerve root injections for pain, ablations for bone and soft tissue tumors, vertebroplasty etc.

6. What is the effect of turf wars on radiology practice, for example, Obstetricians doing antenatal ultrasounds, Neurosurgeons doing vascular neuro-interventions, etc?

Turf wars exist for all branches, for all types of physicians and surgeons. For radiology, these are not new, and radiologists have kept on adapting and innovating their practice over the years. These things play a role if you are planning a standalone private setup and not in institutional practice. Other specialists can “try” to erode onto our turfs but they would be doing a huge disservice to their patients.

7. Is Radiology a dependent branch?

Yes. In fact, ALL branches in medicine are and SHOULD be!

In today’s world, all branches are dependent upon each other and no branch can claim to be truly independent. It is important for doctors of all branches to maintain good relations with each other, whether practicing in institutes or in private. This question of dependence arises only in the private standalone setup and not when working in hospitals or institutes, and then again all branches are in the same boat. 

8. Will Artificial Intelligence (AI) replace radiologists in the future and leave all of you guys unemployed?

As someone who works with AI in radiology, I can say radiology AI is perhaps the most over-hyped thing in 21st-century medicine. It is not going to replace a single radiologist in the 21st century, and I do not know about the 22nd century. On the contrary, AI has exciting new applications which are going to benefit radiologists themselves and improve their efficiency and diagnostic accuracy. At a preliminary stage, AI can to an extent identify certain things not visible to human eyes like autism, ADHD, schizophrenia, certain premalignant tissues, etc. However, there are many practical world obstacles, regulatory and clinical validation issues that AI needs to overcome before it can even be considered in routine practice.

9. What are future prospects after radiology? What different fellowships / DM courses are available after radiology?

This article on the Cafe Roentgen website details the future prospects available after radiology including the various fellowship and DM courses: Radiology Fellowships, DMs, and Super-Speciality DNBs in India.

You can also check out articles on FRCR and EDiR shared previously on our website:

FRCR Exam

European Diploma in Radiology (EDiR) – The Complete Guide!

Coming back to our first question: What is radiology? Dr. Harry Z. Mellins, former Chief of Radiology at Harvard Medical School, USA summed it up really well:

The diagnostic radiologist is a clinician who has sacrificed one of the greatest glories of the practice of medicine and its greatest responsibility—daily contact with the ill and their families—in order to concentrate more on the essence of our profession, the pathology of the living. This he sees through the medium of shadows, which has left him open to the charge of not quite being a real clinician. But shadows, after all, are real. What are we to one another and what is the world to any of us but an inverted image on the retina? Seeing is done with the mind. The camera does not see: it records. The radiologist perceives the shadow, sees the lesion and imagines the man. The bedside physician sees the man, perceives the signs, and imagines the lesion. They practice from the outside in and we from the inside out. Both are clinicians, for in truth there is no other kind of doctor worthy of the name. The decisive test for all is finally and always at the bedside. This then is one concept of the radiologist – with a film on the view box but the bedside on his mind.

No matter which branch you choose, remember it is about selecting what is MOST SUITABLE for YOU. And the patient always comes first. All the best!

Dr. Ameya Kawthalkar
MD, DNB, FRCR, EDiR, DICR
Fellowship in Musculoskeletal Imaging and Interventions, SMK, Netherlands
Consultant Musculoskeletal and Sports Radiologist, Mumbai

If you have any questions, please feel free to get in touch via email at ameya005 at gmail dot com

Still not sure? Check out this article by Dr. Devpriyo Pal which discusses why you should take up radiology: Why did I take up Radiology?

References:

1. Kawthalkar, A. S., Sequeira, R. A., Arya, S., & Baheti, A. D. (2019). Non-radiation occupational hazards and health issues faced by radiologists – A cross-sectional study of Indian radiologists. The Indian journal of radiology & imaging, 29(1), 61–66. doi: 10.4103/ijri.IJRI_403_18
2. Sebastian, B., Keshava, S. N., & Lakshminarayan, R. (2021). The Status of Interventional Radiology as a Specialty among Medical Students in India-Knowledge, Interest, and Exposure. The Indian journal of radiology & imaging, 31(2), 259–264. 10.1055/s-0041-1733813
3. Images and GIFs from : Tenor.com and a medium article by David O.