Life in IR in the US

Created - 11.09.2009

I can only speak for one institution: a large academic centre in the Midwest, where the brightest come, and then move on to the larger cities on the West or East coast. America has an obscene number of hospitals, grossly out of proportion with its populations, in comparison with any country in Europe. This bears witness not only to the appalling state of health of the most powerful country in the world, but also to its obsession with healthcare. If you can't find something wrong with you in this country, then a doctor sure as well will.

The tales of over-investigation and of excessive treatment are generally true, which of course helps people like me because not only are there many studies, but they are in many different modalities which enables me to compare and contrast the values of CT, MRI, angio, nuclear medicine, ultrasound and more. 

Do I sound cynical enough yet...? Ok, I will carry on, but first, let me tell you why it is worthwhile being here. First, from a training point of view, I can't dispute that it is extremely good. Institutions like this recruit from all over the world. Training is very seriously taken, and each institution competes with others for the best medical students. So the residents and fellows in radiology get a huge amount of teaching. The results of exams are published by institution to make sure they keep striving for improvement. Although there is a surfeit of supervision, this does mean that you don't develop bad habits and carry them through until completion. There is no see one, do one, teach one here. More do a whole load with someone else peering over your shoulder, so that when you do stand on your own two feet for the first time, it is a little unnerving. The litiginous society contributes to all this anxiety to avoid mistakes, of course, but I cannot help thinking that we do benefit from the need to get things right. I should add that I miss the world of early exposure to responsibility. They were carefree days.

Fellows are paid poorly here in comparison to the UK. About half as much in fact. And there is no working time directive to speak of. However, the rewards come quickly, and will be good even after the new administration has knocked some sensible restraint into the system. 

Let me conclude by saying that I feel pleased with some of the procedures I have done. High tech equipment, endless support staff, and a wide referral base have enabled me to do some complex IR procedures. The teaching has been good, if a little antiquated. It is a good place to learn, and then return from and get back to some sensible pragmatic medicine. Here is the worst encounter. Not a blink or a raised eyebrow at this one. A 35 year old man of middle eastern origin presents with erectile dysfunction. He has every reason to have problems, having been through a short lived, unconsummated marriage with a woman he describes in unendearing terms. Prior to this there were no problems. Since the marriage he has been given almighty stick by his family who tell him he needs to get married and produce some offspring to be proud of. He feels a little cowed, and this is one of the manifestations.

His urologist carries out multiple tests and refers him to us for angiography of the penile arteries. He gets what he asks for, and intra-coporeal papaverine injections for good measure. My undying memory is of his face as he looked down while a spear was introduced to his shaft. I wonder if his psychosocial problems will ever resolve now. I doubt it. Only in America. 

There are plenty of opportunities over here. USMLE is pretty much a must for IR, but that is not as big a deal as one might think. Once the fellowship is complete, the recruiters chase in packs. America is a big country with all types of work and geography.

Jon Willatt, Ann Arbor University Of Michigan Medical Center