April 15, 2020

Practicing Radiology in the Small and Rural Communities

Daniel Ortiz, MD, is a first-year radiologist in private practice serving communities in northwest and central Georgia.

"Do you like four oh?”

After a very gracious welcome from the radiology department staff on my first day, one of the RTs asked me this question. I had no idea what he was asking me in his thick Appalachian accident. I tried to do the standard affirmative nod and slowly walk towards my reading room. As I walked away, it hit me… He was asking if I liked “fluoro.” I spun around and spent the next couple of minutes talking about the day’s fluoroscopy schedule. He could read the difficulty I was having understanding him and said with a laugh, “You don’t speak Appalachian, do ya?” This was my introduction to practicing in a rural environment and will always be a treasured memory for me.
Having grown up in a suburban environment and completing all my education and training in metropolitan areas, I had no attachment to rural communities when I started practice. After nearly a year of working in rural and small communities, I have grown to love practicing in these areas and have found a deep camaraderie amongst my referring physicians, administrators, RTs, and fellow radiologists.

It’s All About the Patients

These rural hospitals fulfil a critical need in these underserved communities. Often the major employer in a community, they also provide medical services locally, allowing for timely and accessible care. Without these hospitals, patients would have to travel long distances, which could have detrimental effects on their health due to delays in care in the acute setting, as well as with chronic conditions. When I have the good fortune to interact with these patients, either through mammography, fluoroscopy, or needle procedures, they always express gratitude to have someone nearby to provide these services.

A Jack of all Trades

By nature, most small community hospitals are staffed by radiologists practicing as generalists. My perception of what it means to be a generalist has greatly changed since I started practice. Plain film, fluoroscopy, US, nuclear medicine, body CT, and head CT; that is about the extent of what I anticipated a general radiologist to do. Beyond that, in training we are often ingrained with the idea that “if you need to know it, you’ll learn it in fellowship.” It can be easy for a radiology resident to choose to not like a part of radiology and not take learning it seriously beyond what they need to know for the boards (for me it was chest and pelvic MR). Outside of large subspecialty private and academic practices, this couldn’t be further from the truth. Though I’m fellowship trained in MSK radiology, my partners and I will read MRIs outside of our subspecialty. Granted, if an individual study pushes one of us beyond our skillset, we have the culture and IT infrastructure to support case-sharing, either with a second look before signing off a report or asking another radiologist to read the exam.

We’re All Generalists

Further, in small and rural community practices, it is not only radiologists practicing as generalists, but also nearly every other specialty in medicine. In fellowship, I learned the minute nuances that are important for highly complex patients being treated by subspecialty surgeons. Most of the patient population we serve have “bread and butter” conditions that we are all trained to handle in our various residencies. Even if I go into excruciating detail on an ankle MRI, as I was trained to do in fellowship, the general orthopedist may only want or need the 30,000-foot view. The same is true for the general surgeon. For patients with more complex conditions being treated in the communities, it may be worthwhile to get a look from a subspecialist radiologist. Aside from those cases, the most complex cases are most of the time referred to tertiary or quaternary care centers, with subspecialty radiologists and treating physicians who are most apt to take care of those patients. Lastly, in these small communities, often the RTs are cross-trained to acquire images with multiple modalities. One RT comes to mind who not only serves as the site PACS coordinator, but also an MRI RT, ultrasound RT, and occasionally, a radiographer.

Final Thoughts

General and rural practice is often overlooked or looked down upon, but I find it an extremely rewarding career choice. General radiology can be challenging as you’re obligated to keep up with nearly the full breadth of radiology. Luckily, we have great resources such as the ACR Education Center to provide refresher courses to keep up-to-date. General radiology obligates radiologists to be introspective and truly try to understand the full scope of their skillset, filling in the gaps where needed, as well as also having the humility to ask others for help. I encourage everyone in every practice setting to keep up as many skills as much as their practices will allow. At the end of the day, regardless of subspecialty, we are all diagnostic radiologists — a fact strikingly evident today in the era of COVID-19.