Michael c. 1975
For one swallow does not make a summer, nor does one
day.
(Aristotle in Nicomachean Ethics, transl. W. D. Ross)
Michael c. 1975
We flew into Seattle on June 17, 1972 and stayed at the University Motel (only $14/night) for a few days, and also with Rick and Anne Matsen while awaiting our rental house to become available on July 4. Our car arrived by boat a week or so later.
Before my residency started, we enjoyed making our first hiking trip in Washington state in late June 1972 with the Matsens, hiking along the Baker River Trail. We also made a good camping trip to Grand Coulee Dam and Dry Falls, Washington, and Montana's Glacier National Park (also in late June 1972).
Geography, History, and Economy: Washington state is divided by the Cascade Mountains into the dry desert east and the lush rain-soaked west. Seattle and its environs were and are a gorgeous metropolitan area to visit and to live in. I will only provide the barest description of Seattle's topography and environs for orientation purposes, as the region has become so much a part of our lives and is probably well known to most persons reading this. A good capsule history of Seattle since 1940 can be found in Wikipedia. Greater details regarding Washington history can be found in the Online Encyclopedia of Washington State History. The city of Seattle is elongated north to south but narrow west to east, constricted between Puget Sound to the west and Lake Washington to the east. To the east of this lake are Bellevue and Kirkland, to the north are Edmonds and Everett, and to the south, past contiguous small cities such as Tukwila, are Tacoma, and, further south, the capital of Washington, Olympia. Further to the east are Lake Sammamish and the Cascade mountains, while across the Sound are the Olympic Mountains on the Olympic Peninsula. One is rarely without a view toward fresh or salt water or mountains in Seattle.
The major employers in Seattle when we arrived were Boeing and the University of Washington (UW). Boeing had always had its ups and downs, but we arrived during a major Seattle area recession caused by the cancellation of the Supersonic Transport plane in 1971, and the 1973 Oil Shock soon followed. It was not until the 1980s that Microsoft and other high-tech companies added significant diversification to the local economy. While the suburbs have grown rapidly, the city of Seattle has grown only slowly in population since the 1970s, staying between 500,000 and 600,000 inhabitants, with whites declining substantially and minorities making up the difference. One of the attractive features about Seattle to us was the relative diversity of the populace, including a large Asian presence in the International District (formerly known as "Chinatown").
Our Home: Prior to our arrival, we had made the decision to continue renting rather than purchasing a house, based on my modest resident's salary. We rented a pleasant and comfortable home in the View Ridge neighborhood, about 3 miles north of the University of Washington and University Hospital, not far from the View Ridge Playfield. (Perhaps renting was a mistake, as property values rose rapidly while I was a UW resident, but we had little financial cushion to gamble with, and the $200/month rent was hard to beat.) Our neighborhood was not especially flashy or distinctive, but simply a nice quiet area of predominantly single-family homes in which to live and raise a family. I moved into the cool basement room for my study (having to step around the rainwater which seeped in and flooded the floor at times), while we divided the two main floor bedrooms between Wendy (shared eventually with Christie) and Becky and me. The house had shrubs and flower beds, a pleasant fenced back yard with covered patio, a one-car garage, and a decent living/dining room for our modest entertaining.
Culture Shock: Coming from Anchorage to Seattle left us with a feeling of culture shock. We felt as if we had experienced a time warp, emerging as it seemed from the 1950s into the radical early 1970s. Seattle appeared to be a sophisticated and progressive city, and we were intrigued to encounter a burgeoning counterculture of hippies and flower children, at least in the University District, as seen for instance at the fascinating University Street Fair and on the University campus. It was exhilarating to experience the freedom such a diversity of lifestyles implied, even if I never really took the opportunity to plunge in myself (well, maybe a little—I did allow my hair to grow longer as a UW resident when Becky was my barber, though never shoulder length). My old goal of striving to be a "southern gentleman" seemed out of date and out of place now. When I would make the mistake of holding a door for a young woman in the University area, I might get a frosty glare rather than a pleasant thank you, and I had to retrain myself to avoid such "patronizing" behavior. (At least this was how some of the radical feminists characterized it.) I had never been a Male Chauvinist Pig, but I did have to further modify my thoughts and behavior to fit in with the social revolution occurring in relations between the sexes.
Seattle's Golden Age: Despite the need for me to update my mindset and behaviors, the 1970s while I was a UW resident seemed to be a kind of Golden Age in Seattle. Housing was relatively affordable, traffic was light and streets were not crowded (unlike in the 2000s), restaurants were varied and served great food including fresh and abundant seafood, the food markets had an amazing variety of fresh vegetables and fruit, the populace seemed comparatively well educated, cultural and educational offerings were highly diverse and of good quality and often low in cost, opportunities for outdoor recreation seemed endless, and personal freedom and satisfaction were high. Truly Seattle was back then one of America's most livable cities. (It is much more crowded now, with much worse traffic, but still remains a fine city in which to live.)
Rain: Enjoying Seattle required tolerating its sogginess, especially the cold, gray, and rainy winters. When our Chevelle arrived in Seattle from Alaska after several days aboard ship, it had been raining heavily and the car would not start. Fortunately, an experienced hand in this wet environment knew to remove the distributor cap and wipe down the accumulated moisture from the contacts—this solved the problem. A few years later, when we returned late at night from 10 days in Texas, we found the trunk of the same car, which had been parked outside, full of about 6 inches of water. It seems the rear window had sprung a leak and the trunk's drainage hole was plugged up. I removed the plug so future water could drain out. We experienced flooding of the basement occasionally in our first rental home. Thus would we became indoctrinated into some of the special climate features of Seattle. A running joke was that Seattleites don't tan, they rust. It seemed more rainy to us in our first year in Seattle than in more recent years—perhaps this reflects global warming or just that we became better adapted. (Here are some hard statistics on Seattle rainfall for 1948 through 2005, the graph of which seems to hint inconclusively at a downward trend.) Fortunately, the rain and cool weather agreed with us for the most part, and we rarely found that weather prevented us entirely from pursuing our outdoor interests.)
Seattle Society and Friends: As recent arrivals in the Northwest and relative transients at that, we were a long ways away from breaking into Old Seattle society. Our social lives revolved primarily around fellow house staff members and their families, radiology faculty, our neighbors, and a few treasured families such as the Michels who were none of the above. (A bit of doggerel which I wrote for the much later family celebration of Erika Michels's half-century birthday may be seen here.)
Domestic Life and Babysitting Coop: We bought for the first time a Maytag washer and dryer—truly we were settling into full-scale domesticity. Becky had always enjoyed indoor house plants, and added a modest number of new plants to the house. She enjoyed being a housewife and mother, and did an outstanding job of these essential tasks (and did not work outside the home again until the 1990s). One of the most enlightened institutions that we encountered in Seattle was a babysitter coop, which had apparently been organized by University medical house staff spouses before we arrived. As a result of this coop, we never lacked for good responsible babysitters, and because we traded our services using a centralized accounting system for our hours served, there was no cost. Best of all, our children got to meet lots of interesting kids and parents in decent homes. This was a good socializing experience for them all.
Our lives had certainly changed with the arrival of our children, but thanks mostly to Becky's great organizational skills and perseverance (plus the babysitting coop), we were able to continue with very active lives even while enjoying the warm benefits of being parents. We enrolled Wendy in a preschool taught by Pat Devin, which she enjoyed, and she also participated in a rhythm band through the Seattle Park department and in early piano lessons.
 Becky with parents and kids Wendy and Christie May 1974 |
 Becky and Christie c. September 1974 |
 Tina, Christie, Jim, and Wendy December 1974 |
 Wendy and Christie October 1975 |
Christie Born: Our second daughter, Christie Rebecca, was born in late spring 1974, completing our
nuclear family. Her middle name of course honor's her mother, whose name honored Becky's great grandmother. Becky's parents came soon to see their second grandchild.
Family and Kinship Terminology: Christie's birth completed my new nuclear family (that is, our children plus Becky and me). One hopes that, like the not-quite-indivisible atomic nucleus, nuclear families will remain bound tightly together and difficult to tear apart. Family and kinship terminology can be very confusing to me (note 8), with kin and kinship, at least as I prefer to define them, encompassing not just biological ties by blood descent but also "affinal" ties of marriage, adoption, and other rituals, etc. Furthermore, social evolution has brought about continued modifications in our concepts of family. After the birth of our children, I generally refer to my parents plus myself and my brothers as my original nuclear family, or my birth [nuclear] family, or, less precisely, my family of origin. Beyond my new nuclear family, it currently seems easiest to simply group all remaining blood and affinal kin into the useful term, my extended family. Morever, there are individuals who have been important and seemed like family to me, though unrelated by blood or marriage.
Visitors: We were pleased to have a number of visits to Seattle by all of our parents (at least once each year); by Becky's grandmother MaMa each year; and by Becky's brother Charles and his wife Linda (in summer 1974—their first daughter Cayla was born later that year). We also made a fun though mostly rainy trip to Glacier Bay and Sitka in Alaska with Becky's parents and MaMa in September 1975.
Distant Travel and Extended Families: We continued to travel to Texas to visit with our families at least once a year, trying our best to reduce the great geographic distance that separated us. I especially enjoyed making a canoe trip down the placid Guadalupe River in Texas with my brother Scott in December 1972—he had excellent canoeing skills, and went on to become an experienced white-water kayaker. I also drove with my father to visit Russ while he was doing anthropological field work in Teacapán, Mexico (located near Mazatlán, in December 1973). Russ earned his PhD in Social and Cultural Anthropology from the The University of Texas in 1973. We were sorry to miss the wedding of Becky's brother David to Mary, which took place on May 25, 1974.
In June 1975, after taking my radiology oral board exams in Pittsburgh, I stopped in Denver Colorado to visit with Russ and Scott. Both of them were by that point living in Colorado—Russ was now teaching at the University of Colorado in Boulder (as of 2009, he still teaches in their Department of Anthropology as a full professor), and Scott was working as a photographer with the Colorado state archeology team. On that trip, I also visited with old family friend Richard Gonzalez, who had built a nice mountain home near the small town of Evergreen. He named it Monte Sol, and it nicely honored the memory of his wife Loraine, whom we had loved.
We made a fun though mostly rainy trip to Glacier Bay and Sitka in Alaska with Becky's parents and MaMa in September 1975.
Woodworking and Other Projects: I continued to work at various woodworking projects mainly for the kids: a ladder exerciser, a wooden slide, boxes, etc. I also put together some Heathkit electronic projects, including a voltmeter (VTVM) and an ultrasonic burglar alarm (made necessary by a break-in).
Piano: We bought a used upright Everett console piano, which nearly killed me and my neighbor Ken as we struggled to get it moved into the house. It was worth the effort, however, as it has always struck me as having a beautiful tone (for more about the uses we have put it to, see music).
Sailing and Flying: I also tried my hand at a sailing course offered at the University of Washington in 1974, though I did not get very far with this (and must concede that I just don't seem to be much of a sailor, and never wanted to own a power boat). We were taken out as guests of Dr. Byron Ward and his wife on their sailboat for Seattle's Opening Day festivities in May 1974, an enjoyable outing, the only time we have sailed in this traditional Seattle event. A friend John Harley took me up in a rented plane in December 1972, allowing us to enjoy good views of Seattle, Bremerton, and the Puget Sound.
Hobbies, Crafts, Ethnic Cooking, and Gardening: We tried making wine from berries and grape extracts (which turned out pretty good), and also beer (a disaster, as this mostly yielded exploding bottles of yeasty brew). Becky continued to improve her skills at macramé, needlepoint, and a little sewing. She also began the first of many ethnic cooking courses initially at the House of Rice in Seattle in 1972 – 4. These included Chinese, Indonesian, Indian, and Japanese cooking. She went on to take several classes in Asian cuisines from Diana Liu, who taught in her home. Becky still prepares, and I still enjoy, many of the recipes she first learned in those courses. In about 1976, we joined in with four other couples in a "gourmet" club in which the wives cooked meals of various nationalities. Though we were renting our house, Becky also began to get more serious about outdoor ornamental gardening in about 1973.
Lectures and Concerts: During the time we have lived in Seattle, we have tried to benefit as much as possible from our proximity and access to the University of Washington (UW), including attending some of the many excellent concerts given there (see music), as well as occasional lectures especially in later years.
Coursework for Pleasure: While I was still a resident, we began a practice of taking non-credit courses through the University of Washington Extension program (then called Spectrum). We tried to find courses that we could enjoy together, particularly literature, cinema, opera, and science. Some of the many courses we took included: environmental issues (1974); bird identification (taught by ornithologist Dr. David Manuwal in a weekend in May 1975 at the Pack Forest of the University of Washington); and a course on Opera in Seattle (taught by Dr. Charles Troy, beginning in 1975, and repeated over several years). We especially enjoyed two film series: in 1973 on Japanese films, which included Kurosawa's Rashomon (1950) and Seven Samurai (1954), Teshigahara's Woman in the Dunes (1964), Watanabe's Hari Kiri, Mizoguchi's Ugetsu monogatari (1953); and a Truffaut series in 1974, which included Jules et Jim, The 400 Blows, Shoot the Piano Player, The Bride Wore Black, and L' Enfant sauvage. Unfortunately, the local movie theater owners felt that this was unfair competition, and the UW felt obligated to end its excellent film series. Becky also took courses on: mushroom identification (fall 1973, given by the noted mycologist Dr. Daniel Stuntz); the novels of Aleksandr Solzhenitsyn (1975); and the identification and description of ornamental trees and shrubs (c. 1976).
Western US and Canadian Hiking, Camping, and Other Touring: We enjoyed making our first hiking trip in Washington state in late June 1972 with the Matsens, hiking along the Baker River Trail. We also made a good camping trip to Grand Coulee Dam and Montana's Glacier National Park (also in late June 1972, before my residency started)
We continued to enjoy hiking every chance we got, especially in the Mt. Rainier National Park (MRNP), Snoqualmie Pass, and Mt. Baker areas, often combined with car camping. These included a fine hike to Spray Park in August 1972, at which time we camped in Ipsut Creek Campground in MRNP, and the spectacular Table Mountain Loop hike at Mt. Baker in October 1972. Becky joined me in March 1973 on her first backpacking trip, to Sand Point and Cape Alava on the Pacific Coast of the Olympic Peninsula—it rained almost constantly but was nevertheless very atmospheric and scenic. We made some other fine backpack hikes during these years, to: Blanca Lake (June 1973); Grand Valley and Pass in Olympic NP (July 1973); Polallie Ridge (August 1973); Moraine Park in MRNP (August 1974); and Indian Henry's Hunting Ground in MRNP (August 1975). We had an especially memorable trip in June 1973 down the Oregon coast to Eureka, California, then on to the Trinity Alps, Mt. Shasta, Lava Butte, and Crater Lake Oregon, car camping and doing a number of short hikes. Other great camping trips included: Jasper and Banff NP in Canada in September 1973, which we made with friends Carol and Bill Warren along with our three children; and the west coast of Vancouver Island in September 1974, also with the Warren family. On some excursions, we stayed in notable lodges, including: the Manresa Castle in Port Townsend (September 1974); and the Quinault Lodge and Kalaloch Lodge on the Olympic Peninsula (April 1975) The latter was just after losing our dog Freude—she had become paraplegic, as is unfortunately too often the case with dachshunds. We also stayed in cabins of friends (including a nice house on the water in Shelton in 1972 and 1973). In about 1975, we began a summer tradition of renting a cabin on the beach in the San Juan Islands for a week or so, either at the Beach Haven Resort on Orcas Island or at Lonesome Cove on San Juan Island. This continued until we purchased a recreational property of our own.
I combined business with pleasure on a trip to San Diego in May 1975—I drove there to attend a radiology chief resident's meeting, visiting with friends along the way, and Becky flew to meet me in San Diego. We visited the San Diego Zoo and SeaWorld, and then drove back together, stopping at San Juan Capistrano and to hike in Sequoia NP and Yosemite NP. Yosemite was, however, too packed to find a campground in, and we ended up staying in the lodge there.
Downhill Skiing, XC Skiing, and Snow Camping: We made occasional downhill ski outings, especially to the nearby Snoqualmie Pass area. We especially enjoyed an overnight stay at the Alpine Inn at Crystal Mountain near Mt. Rainier in March 1975 for downhill skiing. (Travel to this prime ski area required about twice the time.)
We also kept up XC skiing when we could, though we found the heavy wet snow and mostly steep terrain of the Pacific Northwest much less favorable and inviting compared to the ideal conditions we enjoyed in Alaska. (In Anchorage, for example, there was readily available XC skiing in town and nearby, the temperatures were consistently well below freezing and thus optimal for employing the easy-to-use blue or green XC ski waxes, and there was ample gently rolling terrain with modest slopes and low avalanche risk.) On one trip (April 1976), we stayed in Randle and XC skied at White Pass, having beautiful views of Mt. Rainier, Mt. Adams, and the Goat Rocks Wilderness.
We did at least two XC ski overnight camping trips in the winter: to the Reflection Lakes in Mt. Rainier National Park with the Matsens (February 1974); and by ourselves to nearby Upper Dewey Lake in the Naches Peak area (April 1973). On the latter trip, we skied in across a slope on a slushy warm April afternoon. Our friends who had accompanied us departed before darkness, leaving Becky and me to enjoy camping out on the snow in this beautiful setting looking out toward Mt. Rainier. But when we tried to ski out the next morning, we discovered that the slope had frozen solid, and what had been a very safe traverse coming in was now deadly dangerous. At one point, I twisted abruptly to catch my balance in these treacherous conditions, and my backpacking tent flipped out of my pack and skidded down the slope, eventually disappearing over the side where the slope suddenly became precipitous. This was probably the most foolhardy thing we have done in the outdoors, and the closest we came to getting ourselves killed, in this case through poor planning (i.e., not anticipating how different the snow conditions might be in the morning). That summer, we returned to this area on a snow free hike, guessed at where the tent had gone over, and persuaded some skeptical mountaineers that we ran into to descend the steep slope on their ropes and retrieve our tent. They were amazed to find it pretty much where we thought it would be, considering how different everything looked without the tens of feet of snow-pack. I was relieved to have gotten back our 2-man North Face tent, which I had first used in Alaska and which therefore had sentimental as well as monetary value.
Tennis, Jogging, and Cycling: During my residency years, Becky took up playing tennis more seriously and regularly, made feasible by the ready availability of baby sitters through the coop. She generally played doubles at city parks and at Sand Point Naval Station with a regular foursome of women, and also played in the flights at Laurelhurst Park. In addition to skiing, I continued to play tennis off and on when time permitted, and took up jogging, usually running about three miles in the neighborhood late at night. I often commuted to the University Hospital on my bicycle, weather permitting—for this purpose, I bought a nice ten-speed Nishiki touring bike for $55 soon after arrival in Seattle.
Autos: We also bought a used 1973 green Toyota Corona coupe from fellow resident Beth Carter in about 1975, in which, like my Corvair, I enjoyed commuting and zipping about town. We were again a two-car family (though the aging Chevelle required a complete engine overhaul in 1975).
Dining Out: Seattle by the 1970s already offered a great diversity of restaurants, exceeded only by New York and San Francisco among cities we had spent time in. When eating out in Seattle, we tended to go especially to Chinese restaurants. We were newly introduced in Seattle to several different Chinese cuisines—especially the Harbin for Northern Chinese cuisine, the King Cafe for dim sum, the no-frills Inn Bin for great egg rolls, and our aging and somewhat dumpy standby, Tai Tung, for diverse Chinese offerings including one of our longstanding favorites, Squid Chinese Style. We were hard-pressed to find decent Mexican food in Seattle in the 1970s (the situation has since much improved). However, excellent seafood had long been available (e.g., Ivar's Salmon House, or Ray's Boathouse if you could afford it); a good burger could be had at Kidd Valley; and a fully decked-out pizza was offered at the Northlake Tavern. I also liked the Ali Baba for Middle Eastern fare (alas, now defunct). The 1970s as far as I recall largely preceded the wave of interest in other Asian cuisines such as Thai, Vietnamese, and Indian.
Concerts, Theater, and Movies: I have summarized our richly rewarding involvement in Seattle musical life elsewhere. We attended a variety of plays at the Seattle Repertory Company (e.g., Hamlet) and at ACT (e.g., When You Comin' Back, Red Ryder?; Of Mice and Men; and Oh, Coward). Movies I especially enjoyed during 1970 – 1975 included Patton (1970), M*A*S*H (1970), Deliverance (1972), The Godfather I and II (1972 and 1974), American Graffiti (1973), Chinatown (1974), The Sting (1973), and Jaws (1975).
Media: Although I do not recall which TV programs we watched (probably not very many in those years, other than national news), we bought in 1975 our first color TV, a Magnavox, to supplement our old 13" black-and-white. We enjoyed the Seattle Times in preference to the Post-Intelligencer (as of 2009, the latter is regrettably no longer publishing a print edition), and continued to read Time as well as my various scientific and medical journals.
Politics and Environmentalism: As in previous years, I tended to keep my head down and buried in work, but politically these were the years of the corrupt 1972 re-election of President Richard M. Nixon (in which George McGovern, whom I voted for, was soundly defeated); the elevation of Gerald Ford to Vice President when Vice President Spiro T. Agnew was forced to resign (1973); Nixon's re-election Watergate scandal, impeachment, and resignation (1972 – 74); the succession by President Gerald R. Ford (1974 – 1977); and the humiliating end of the Vietnam War (1975). In the environmental movement, these years included the Water Pollution Control Act (1972) and the Endangered Species Act (1973, see References).
Supporting Worthy Organizations: In addition to our support over several previous years of the Audubon Society, we began making donations to other favorite causes in 1974, namely NPR's KUOW, and PBS's KCTS, the Sierra Club, the Nature Conservancy, and United Way. Our former alma maters Rice and Baylor Med soon followed. See also here.
Health and Satisfaction: I enjoyed robust good health during my residency years, noting only borderline hypertension, which was worked up and for which I was treated with a low salt diet and medication for a while. These were very hectic and hard working years for me, but also very satisfying years for both of us.
Why I Chose to Specialize in Radiology: I have already mentioned earlier factors contributing to my interest
in diagnostic radiology as a career. There was never a flash of revelation or conversion
for me regarding going into radiology. My gradual and eventual adoption
of radiology and nuclear medicine just proved to be a very natural, rational, and positive development. As of the time I entered the residency
program (July 6, 1972), my reasoning can be summarized more completely as follows:
(1) My background and
interest in physics, math, and complex
physical technologies were a good match with the high technology aspects of radiology;
(2) My experiences in the M. D. Anderson Hospital physics department servicing
radiology needs were very satisfying and interesting;
(3) Dr. John A. Burdine,
Jr.
had sold me while I was in medical school on the growing field of nuclear medicine (NM) in particular;
(4) I had concluded from my seven year exposure to the various ways to practice medicine that I was not
ideally suited to become a primary care physician, and that radiology would just be the best fit for my skills,
personality, and interests, more so than any other field of medicine;
(5) My
experiences with medicine at its most stressful convinced me I would likely do
better in a specialty in which I could better control the demands on my time;
and
(6) Radiology was known to offer readily available and highly diverse career
opportunities, some of which provided good financial compensation, high
career satisfaction, or both.
Medicine was certainly a major interest in my life, and dominated my waking hours, but I was interested in many other things as well (as these memoirs reflect), not the least being my family, and I wanted to have time to enjoy a richly varied life.
Memoirs versus the Quiet Reserve of Radiologists: It seems that radiologists rarely, so far as I am aware, get around to writing their memoirs for public consumption, or honoring more than one or two of their mentors in print. Perhaps this is in the nature of radiologists, reflecting how busy they are, their technological focus, or the discreet caution they exhibit, wishing to avoid embarrassment in writing about contemporaries, avoiding retribution for adverse statements made (particularly in view of their unique vulnerabilities), or just generally wanting to keep a low profile. I'll try to find a decent balance, keeping these observations for the most part uncontroversial and appropriately restrained, while provided sufficient detail to paint a true picture of this honorable profession as I experienced it.
Thinking back to those residency years and looking over my jam-packed appointment calendars, I realize it is not possible to fully describe the four years I spent, or to adequately honor the faculty, outside practitioners and visiting lecturers, and support staff that I interacted with. I can only touch on some of the highlights such as I recall them (sadly, rather dimly at this point). Moreover, I can only barely scratch the surface in mentioning the complex array of technologies and procedures we were working with.
Structure of the Teaching Program: The diagnostic radiology residency consisted of three years of training beyond internship (what would now be termed years R2 through R4). I do not recall if any purely radiology internships existed in those days, and most of us had done rotating or straight medicine internships (R1 years) prior to our residency. Although in the more distant past, radiology training had combined diagnostic radiology and radiotherapy, and there were still some general radiologists doing both therapy and diagnosis, by the time of my residency, radiology had permanently split into these two entirely separate disciplines. My time in residency training barely extended into the beginnings of the explosion of newer radiology imaging modalities, in particular computed tomography (CT) and diagnostic ultrasound (US). Magnetic resonance imaging (MRI, formerly termed nuclear magnetic resonance imaging) was several more years further in the future. We spent our time performing or assisting with procedures, and in a wide variety of university didactic conferences (including radiology-pathology correlation conferences and "Grand Rounds"), case discussion meetings (including nuclear medicine and eventually ultrasound "scan meetings"), classroom lectures (such as in radiation physics and radiation biology), journal clubs, etc. Some of these conferences were put on by other institutions as regional conferences. One useful learning opportunity was the subscription series of UCSF neuroradiology videotapes shown weekly in c. 1974 to 1976 at Providence Medical Center by Drs. Paul Paulson and Gerold Garrett. These evening sessions exposed me to that hospital environment for the first time. (I passed up the cocktails which were generously served.)
On-Call Duties: We were on-call about every fifth night and weekend as residents. (At the VA Hospital early in my residency, we were also sometimes assigned at night or on weekends to serve as "Admitting Officer of the Day" or AOD—in which we nervously attempted to resurrect our rusty general clinical skills and decide what to do with patients who presented at night with acute medical conditions. Fortunately the radiology residents were soon relieved of this uncomfortable task.)
UWMC Affiliated Teaching Institutions: The residency in radiology in the University of Washington medical system was very spread out and involved multiple institutions as well as practitioners coming from all over the region to teach. Currently, the term UW Medicine is the broadest umbrella term that is used to describe the UW health system. The term UW Medical Center (UWMC) apparently is now used to describe the extensive complex of buildings at 1959 NE Pacific in Seattle, including what at the time we called the University Hospital (or UH, a term apparently now obsolete). Closely affiliated then and now was Harborview Medical Center (HMC). As residents, we also rotated through the more loosely affiliated Seattle VA Hospital (SVAH, now called VA Puget Sound, Children's Orthopedic Hospital (COH, now called Seattle Children's), and the Seattle US Public Health Service Hospital (no longer a hospital, but home of Amazon.com and some clinics). The UW currently services a number of outpatient facilities as well, but these were not a part of my residency experience, aside from Hall Health (the student health center on the main UW campus).
Faculty and Staff: The chairman of UW Radiology at the University Hospital and in the UW system, and therefore my ultimate boss, was Dr. Melvin M. "Mel" Figley. He was a well-respected specialist in cardiovascular and chest radiology, and a truly dedicated physician. His mastery of chest film and coronary arteriography interpretation, among other skills, were unexcelled and truly inspiring. He was rather stiff in manner, and did not readily put a nervous first year resident at ease when working around him. He would often refer to "getting comfortable" with the findings on a plain radiograph (i.e., an "X-ray" or "film"), but I rarely felt comfortable around him, though I certainly had great respect for him. I recall a fellow resident who Dr. Figley asked to stand rather than sit while working at interpreting films—the resident had the temerity to request an exception, which was granted, after he mentioned that he had been up most of the night on call. Despite his extraordinary interpretive skills, I also had some concerns as the years progressed as to just how effectively Dr. Figley was able to advocate and fight—in the admittedly complex and internecine politics of the UW Medical Center—on behalf of the needs of the radiology department and its residents, especially in securing funding for expensive new technologies. (I'm not suggesting I could have done any better had I been in this unenviable position.) We got along well, however, and Dr. Figley honored me by naming me while I was a second year R3 resident to be chief resident during my third (R4) year of residency (out of five residents), doing his best to groom me for a career in academic radiology.
The radiologist assigned to keeping us in line and assuring that we were learning what we needed to learn was Dr. Rosalind H. "Ros" Troupin. She is a general radiologist who followed the model established by probably the first successful female radiology educator, Dr. Lucy Frank Squire (1915 – 1996). Dr. Squire had written Fundamentals of Radiology in 1964, an immediate success with medical students including myself, and like Lucy Squire, Ros wrote an instructive textbook, Diagnostic radiology in clinical medicine, which was published in 1973. Ros was tough but good at her job, and also a person I greatly respected and appreciated.
Another favorite teacher in the system was Dr. C. Benjamin "Ben" Graham—an inimitable pediatric radiologist whose wry wit was a joy to experience. He worked with the also unique Dr. Byron Ward (c. 1924 – 1992, the son of Swedish Tumor Institute founder Dr. Charles B. Ward, and the head of pediatric radiology at COH). Like Dr. Figley, Ben was masterful at extracting the absolute maximum of information from a chest film, in his case typically fuzzy films of very little persons. His life had been altered by a serious bout of polio, but though confined to a wheelchair, and with the support of his wonderful wife Pearl, he had made the most of his intellectual abilities and was much beloved by his admiring residents. A favorite recollection of mine is his often mentioned alter ego—the fictional medical practitioner, Dr. Walter P. Bunczak (I don't recall the precise spelling), who might have had some distant kinship with P.D.Q. Bach. Dr. Bunczak specialized in a variety of what today we might call alternative therapies, including Electric and Magnetic Medicine and other innovative treatments, and Ben's recountings of the good doctor's exploits would always get a laugh.
(I had the pleasure of seeing Drs. Figley, Troupin, and Graham, along with many others from my residency days, at an event in June 2007 celebrating Dr. Figley's illustrious career. See photo at right. Left to right are: F. Christian "Chris" Killien, Curtis "Curt" Northrop, Rosalind "Ros" Troupin, G. Thomas "Tom" Ruebel, Melvin M. "Mel" Figley, John W. Barton, Elizabeth "Beth" Carter, myself, John D. Harley, and C. Benjamin "Ben" Graham. Photo by Dr. Eric Stern. I have no group photos of my radiology faculty, residents, and staff from my residency days—unlike in nuclear medicine, apparently none was made, which is unfortunate.)
I also liked Dr. Leon A. Phillips (who specialized in radiology of the genitourinary tract, and who was the departmental gadfly, upholding and promoting a high standard for ethical and efficacious professional behavior, including the "custom-tailored urogram"); Dr. Curtis Northrop (who along with Dr. Gerald "Gerry" Smith added very desirable intellectual stimulation and challenge at Harborview Medical Center radiology); Dr. Theodore "Ted" Margolis (a superb neuroradiologist who had trained at UCSF); and Dr. Frederic E. Templeton (an elderly pioneer in gastrointestinal radiology who, like Dr. Figley, was a gracious host at his home on several occasions for the residents, and who gave us each a copy of his classic textbook X-Ray Examination of the Stomach, which had been updated in 1964. Dr. Robert L. Leighton, head of SVAH radiology, was an old-timer who liked to claim "Often wrong, never in doubt"—he was an entertaining raconteur and helped to introduce us to the exotic selections at Tai Tung Chinese Restaurant. He was assisted by an outstanding new member of the faculty, Dr. John Harley, who took over as departmental head at SVAH in c. 1974 upon Dr. Leighton's death. Dr. John W. Loop, head at HMC radiology and more of a philosopher than an activist, also was noted for some of his sayings including "A job not worth doing is not worth doing well".
Radiation Physics was taught by Peter Wooten PhD, who managed to make an already difficult topic virtually incomprehensible, at least to many of my frustrated fellow radiology residents. We learned a lot of Radiation Biology, an understanding of which was essential for becoming a well-informed radiologist, from Drs. Kenneth Jackson and Gerald Christensen.
I worked with many fine and highly skilled staff persons, but do not recall their names well. However, they included Mac Shin, Steve J., and Phyllis M.
Fellow Radiology Residents: During my first (R2) year as a radiology resident (1972 – 73), I enjoyed the wisdom and humor of seasoned third year (R4) residents: Paul M. Chikos (who later joined the staff at the VAH and helped John Harley build the department's excellence); Stephen J. "Steve" Reibman; Duff H. Walker (who moved to Alaska afterwards); and Rush A. Youngberg (who was a good friend and with whom Becky and I and his wife Sylvia made several hikes). Our chief resident was Philip W. "Phil" Anderson, who specialized in orthopedic radiology and taught us how to perform arthrography. The second year (R3) residents above me included John A. Boyes, Ross T. Eto, and Mark A. Studley. My own initial cohort of R2 residents consisted of: John W. Barton, Elizabeth J. "Beth" Carter, and G. Thomas "Tom" Ruebel.
In my second (R3) year (1973 – 74), we added incoming R2 residents Robert "Bob" Elliot, David "Dave" Gambill, Jack H. Hirsch, and George A. Weis (and Norman T. Ikemoto as an R4). MIchael J. "Mike" Meagher returned to the residency program for the 1973 – 74 academic year, joining my R3 group, after completing a stint in the naval submarine service.
In my third (R4) year (1974 - 75), we added R2 residents David K. "Dave" Brewer, Robert A. Hoff, Thomas D. "Tom" Rowley, and James P. "Jim" Wilhelm.
When I was in my fourth (R5) year as a UW resident (my first and only year as a nuclear medicine resident), the radiology residency added R1's Michael T. "Mike" Ricci and James V. "Jim" Rogers, R2's Ronald "Ron" Shriver, Geoffrey S. "Geoff" Ferguson, Joseph H. "Jay" Delaney, and Juliette M. "Julie" Engel, and R3 E. Robert "Bob" Butenko.
Textbooks and Radiology Literature: A few of the many textbooks I made great use of during my radiology residency included: Johns The Physics of Radiology, 3rd Edition (I now own the 1983 fourth edition), Margulis's Alimentary Tract Radiology, Caffee's Pediatric Radiology, Felson's Chest Roentgenology, Sutton's Textbook of Radiology, and Newton and Pott's Radiology of the Skull and Brain. Radiology textbooks were becoming increasingly massive and expensive, and though I bought some of these, it was apparent that individually owning most of the major textbooks one would want to use in training and in practice was no longer feasible. As in medical school, I tried my best to read through a major textbook while on each specialty service, in order to try to acquire a reasonably comprehensive exposure to the subject at hand. (However, some of the radiology texts such as the Newton and Potts works were of such monumental length and complexity that this was not always feasible.) Of course by the time I was a resident, it was often necessary to turn instead to scientific papers in the radiology journals previously mentioned, in order to glean the latest information on current and rapidly evolving procedures, and my invaluable reprint collection grew considerably in these years and beyond.
X-ray Equipment and Procedures: At the University Hospital, we enjoyed a good assortment of current-generation diagnostic radiology equipment, which helped to make the resident's experience almost complete for our era. At the most basic level were standard X-ray tubes and tables for making plain film exams (optimally termed radiographs but often simply called in the vernacular "X-rays"), such as on as ankles and elbows, etc. Some of the tables were equipped with linear tomography, used for tomographic exams such as intravenous pyelograms or IVPs (that is, exams of the kidneys, ureters, and bladder in which "slices" through the kidneys were made). We also had fluoroscopy units and tables (on which we performed upper GI exams and barium enema colon exams, etc.), as well as mammographic units.
One especially sophisticated device performed hypocycloidal polytomography and was called the polytome for short. It could make amazingly good cross-sectional images of the bony structures in and about the middle ear, including the cochlea and semicircular canals, etc. This marvel of engineering was eventually supplanted by CT and MRI scanning. (I enjoyed getting to know the senior technologist, Mac Shin, who operated the polytome, and who became a good friend. Mac and his wife Rose shared many an excellent Chinese meal with me and my family over the ensuing years.)
The most seemingly diabolical device in the department was the rotating chair used to perform pneumoencephalography, a neuroradiological procedure resembling torture that thankfully has been consigned to the dustbin of history as a result of CT and MRI. In this procedure, air was injected, usually into the spinal canal in the low back. The air ascended by its buoyancy into the head, and the patient was then rotated upside down and into all sorts of strange positions in order to film the pattern of air filling the intracerebral ventricles, usually looking for intracranial tumors.
Another exotic procedure that required delicate precise technique was the lymphangiogram. Using a blue dye injected between the toes, we would find the tiny lymphatic vessels on the foot, cannulate them (i.e., place an equally tiny needle into the vessel), and inject an oily contrast medium. This would allow display by means of X-rays of the "opacified" lymph nodes of the retroperitoneum in the abdomen (typically looking for lymphoma or metastases from testicular cancer, etc.) Fortunately, this procedure has also been supplanted by CT scanning.
We also learned much about arthrography, bronchography, injections of contrast media into nephrostomy tubes or colostomy stomas, etc.
Angiography: Another key modality in which we gained extensive experience was angiography, the injection into blood vessels of liquid contrast medium for the purpose of making X-rays of the course and patency of these vessels (such as for identification of abnormal narrowings, vascular malformations, or deviations caused by tumors, etc.) We learned cerebral angiography particularly from Dr. Margolis, and peripheral and other forms of angiography from Drs. Howard Ricketts and John Harley among others. Unlike in some training programs, our residents acquired extensive experience in angiography by the time of graduation, and I continued to perform a variety of angiograms for many years afterwards, until the vascular procedures simply became too specialized and complex to continue in the midst of my other work.
Computed Tomography: We were not, in the UW medical system, always the first to acquire the latest in newer generation and increasingly expensive equipment. I had to scramble to gain exposure to cranial computed tomography while still a resident. Computed tomography (CT) was invented in c. 1972 by Godfrey Hounsfield of EMI and independently by Allan McLeod Cormack (for which they won the Nobel Prize in 1979). Initially, because the images were made solely in the cross-sectional or axial plane (cut like a salami slice), the process was termed Computed Axial Tomography, thus "CAT" scanning. However, subsequent improvements led to reconstruction of images in a variety of planes (coronal, sagittal, oblique, etc.), so the name was generalized to computed tomography. The first CAT scanner in Seattle, which imaged heads only, was an EMI unit installed at Virginia Mason Hospital in c. 1974—the busy service was headed up by Dr. Margolis, who like many other academic radiologists had migrated to private practice. I was able to spend some elective time with him there in 1974 or 1975, learning some of the basics about this exciting new modality. The images were remarkably fuzzy by current standards, but one could definitely make out an intracranial hemorrhage, and this was very impressive technology for its time. CT technology has steadily improved, and with the newer generation machines, I have never ceased to marvel at and be awed by the superb views of the inner structure and workings of the body which it affords. (Such information was virtually impossible to obtain as recently as when I was in medical school, and only at autopsy or exploratory surgery were some significant disorders discovered.) The first "whole body" CAT scanner in the Northwest was installed at my future professional home, Providence Medical Center in Seattle, probably in 1976.
Diagnostic Ultrasound: By my third (R4) year of residency, in 1974 or 1975, it was also apparent to me that diagnostic ultrasound was becoming an important emerging technology that I wanted to be a part of. The clinical implementation of this modality was then in its infancy, tracing its routes back to sonar and to the development at the University of Colorado in Denver by Douglass Howry and Joseph Holmes of the hand-held articulated arm compound contact B-mode scanner in about 1963 (see here and References). These were initially "bistable" devices in which the image was made up only of black and white patterns. However, "gray-scale" equipment—which displayed multiple shades of gray as well as black and white—soon followed, and improved the images significantly. In order to receive training at the University Hospital in this technology, I worked during another elective period with the obstetrician Dr. Susan "Sue" Conrad. She was a crusty old-timer who seemed to believe ultrasound equipment belonged in the hands of obstetricians, and maintained an iron grip on the scanner, but she was willing to let me in on some of its secrets. (This experience gave me a taste of one of the many turf battles I would encouter in my practice.) We were using the old style articulated arm B-mode scanner (not the much better real-time scanners yet to be made available, probably in the late 1970s to early 1980s), and I was chagrined that the UH radiology department had not secured an ultrasound scanner of its own. Soon thereafter, however, the radiology department did acquire its own ultrasound scanner, and Dr. Catherine Cole-Beuglet headed up the nascent program. I took the opportunity to work with her in ultrasound during an elective period while I was a nuclear medicine resident (1975 – 76). Eventually I made this field one of my key subspecialties (along with nuclear medicine).
Chief Residency: Dr. Figley honored me by appointing me as chief resident for my third (R4) year of radiology residency (1974 – 75). As chief resident, I was in charge of coordinating resident on-call schedules and helping with coordinating guest speakers. I served to some extent as an interface on sticky issues arising between the faculty and the residents. However, the most critical responsibility of the chief resident was knowing how to run the slide projector without spilling the speaker's slides all over the floor (something I came close to doing with one of Ros Troupin's carefully prepared presentations).
Professional Meetings: I traveled to Vancouver, British Columbia, for the meeting of the Association of University Radiologists (AUR) in May 1973. This was probably the first major radiology meeting I attended, and many more would follow in the years ahead. During my residency, I also attended the superb UCSF diagnostic radiology seminar (1974), the American Association of Academic Chief Residents in Radiology (A3CR2) meeting held in conjunction with the AUR in New York City in May 1974 (for which my way was paid as the chief resident-elect), and the A3CR2 and AUR meetings held in San Diego in May 1975.
Income and Moonlighting: As a UW resident, my income from the UW was a modest $600/mo, and (as a result of my PHS service as a commissioned officer) I also received $298 to $388/mo in GI Bill educational benefits for the first 24 months. This was a significant step down from my Alaska PHS days, though not a real hardship.
With growing family needs, during my second (R3) year of radiology residency, I began various moonlighting jobs, providing basic radiology services, mostly on the weekends. These gigs, which continued into my later years of residency, included working for or at:
(1) Ballard Hospital (under Drs. Stead and Moix, 1973 – 74);
(2) Hall Health Center (the student health center at the UW, in 1974);
(3) Northwest Hospital and other sites serviced by Drs. Stevens, Hesch, et al (beginning in 1974 as a third year R4 resident);
(4) The Northwest Industrial Medical Center (in 1974, beginning as a third year R4 resident);
(5) Aberdeen and Raymond area hospitals (under Dr. Robert Cihak, on the west coast of Washington, in 1975);
(6) A Sitka Alaska locum tenens (in which I filled in for Dr. Loop in January 1975, an interesting trip that had to be extended due to glare ice formation on the Sitka runway);
(7) Stevens Memorial Hospital (under Drs. Aldridge and Wirtala, 1975 – 76); and
(8) An American College of Radiology Efficacy Study (1975 – 76).
In addition to the obvious income benefits and real-life practice experience gained from moonlighting in radiology, I rationalized that these moonlighting jobs facilitated getting to know some of the local area radiologists, helping to pave my way for future job searches. As I recall, even our residency coordinator tacitly approved of or at least did not actively discourage this activity. Moonlighting as a resident, however, is currently officially discouraged at the UW. Their policy in 2009 states: "...Such activities are discouraged, believing in general that the time and effort required for training is a full-time endeavor that should be the resident/fellows’ highest priority at all times."
Board Certification in Diagnostic Radiology: We had earlier taken the written exams required for this certification in June 1974, given at the UWMC. In June 1975, I took my radiology oral boards in Pittsburgh Pennsylvania, passed, and was awarded the all-important Board Certification in Diagnostic Radiology as of June 7, 1975 by the American Board of Radiology. (By 2009, radiology board certification requires five years of approved training: one of clinical training, like my internship, and four specifically of radiology, compared to my 3 years at that point. I received lifetime certification, but the ABR now advises all diplomates to undergo periodic Maintenance of Certification. I have not engaged in recertification due to medical retirement.)
I was potentially ready to venture forth to practice my chosen specialty. My certification is for my lifetime and is not time-limited, but the board now recommends voluntary taking of recertification exams (Maintenance of Certification). I have not taken the opportunity to do this, however, due to health limitations and retirement.
Department of Nuclear Medicine faculty, residents, and staff at UW April 1976
Front row: residents Mike Spiger, Mike Daly, Michael, Ed Schlenk, and Jim Hannah
Second row: includes faculty Tom Rudd, Wil Nelp, Dave Williams, Dave Allen, Charlie Chestnut, and Tom
Lewellen
Third row: faculty Glen Hamilton and Bob Griep
Why I Chose to Also Specialize in Nuclear Medicine (NM): It was apparent to me during my radiology residency that completion of the then standard three
years of diagnostic radiology residency (preceded by internship) did not confer a high degree of
competitiveness for breaking into the tight Seattle job market. Many of
the prized downtown jobs understandably went to persons who had acquired
superior skills in some subspecialty of radiology beyond the basics learned in
residency. Such subspecialty areas within radiology included, among others,
pediatric radiology, neuroradiology, nuclear radiology, and interventional
radiology. Getting a job at least in the Seattle area could be very tough in part due to the high perceived desirability of living there. (This was what we
called the "Mount Rainier Factor": a significant downward
adjustment of salary and job availability resulting from the spectacularly
beautiful volcano on our horizon.) Hoping to improve their
skills and competitiveness, some radiology residents even in those day continued on to
do a fourth year—designated either as an R5 residency year or a fellowship—in subspecialties within diagnostic
radiology. (This practice became even more common and expected of residents in subsequent years.)
In addition to these job-seeking considerations, I also retained an intrinsic interest specifically in nuclear medicine (NM) which began, as mentioned, in medical school under Dr. John Burdine, and I felt I could find a home for my interest in physics, even nuclear physics, in this field. Moreover, Dr. Wil B. Nelp, the department head, was also a good salesman for the field, and helped to convince me, during my rotation on NM as a radiology resident, to continue on for more nuclear medicine training.
Furthermore, the academic year 1975 – 76 would be, as I believed, the last year in which a resident in nuclear medicine could qualify for board certification in nuclear medicine after only one year of nuclear medicine training, provided he/she had previously completed training in diagnostic radiology, which included appropriate introductory training in nuclear medicine, radiation biology and physics, etc.
Fellow Residents: While all of my radiology resident colleagues finishing in 1975, as far as I recall, went directly into practice, I stayed on at the UW for an additional (R5) year of nuclear medicine residency. (They did not choose to call this a fellowship, and the salary was correspondingly lower.) My cohort of nuclear medicine residents in this 1975 – 1976 year were Michael J. "Mike" Daly, James E. "Jim" Hannah, Edward F. "Ed" Schlenk, and Michael J. "Mike" Spiger.
Faculty and Staff: Dr. Nelp, our chairman, was a fine teacher and a very effective department head, adept also at guiding research projects and publishing papers and thus of securing research funds to purchase equipment and hire staff. He had trained with one of the pioneers of nuclear medicine, Dr. Henry N. Wagner. Dr. Nelp worked with the physician Dr. Charles H. "Charlie" Chestnut and with some very talented physicists, most notably Dr. Thomas K. "Tom" Lewellen, to put together some impressive research on analysis in vivo of human whole body calcium using the technique of neutron activation analysis. In this process, a patient is irradiated by neutrons generated by a cyclotron. These neutrons convert calcium in the body to radioactive Argon-37, which can then be measured in the exhaled breath (see References). The nuclear medicine departments of the UH and the affiliated institutions also employed: Dr. David "Dave" Allen (an innovative radiopharmacist); Dr. David L. Williams (another fine physicist); Dr. Robert J. "Bob" Griep (a knowledgeable thyroidologist and future frequent consultant); and Dr. Thomas G. "Tom" Rudd (a multitalented man who taught us about radionuclide cerebral ventricular shuntograms and venograms, and eventually pursued radiology training as well). There were also several noteworthy cardiologists working on the new techniques in nuclear cardiology, including Drs. Glen W. Hamilton and James L. "Jim" Ritchie. Dan H. Chadwick was the hard working and intelligent chief technologist at UH nuclear medicine, a pleasure to work and train with. It was a fascinating and diverse group of folks to work with and to take inspiration from, and I found this year quite stimulating and helpful professionally.
Textbooks and Medical Articles: The textbooks I especially made use of during this year were the bible of NM, Henry Wagner's pioneering 1968 Principles of Nuclear Medicine, Price's Nuclear Radiation Detection, The Radiological Health Handbook, and a text on nuclear physics which was probably Evan's 1955 The Atomic Nucleus. Of course, I also continued to expand my collection of essential papers and reprints in nuclear medicine as I had in radiology.
In Vitro Testing of Specimens: As I did not make subsequent use of them in my NM practice, I will not discuss in detail the many interesting in vitro ("test tube") laboratory NM procedures that I learned about. These typically would make use of a well counter and specimens obtained from patients, and included: radioimmunoassay, the Schilling test, blood volume measurement , etc.
Non-Imaging In Vivo Procedures: We made use of various non-imaging instruments in NM for in vivo testing or for radiation monitoring, such as the Geiger counter, the gamma ray scintillation spectrometer, and the scintillation detector probe capable of measuring for instance the time course of uptake and excretion of a tracer substance given to the patient. This type of testing was most frequently used in evaluation of the kidneys and thyroid.
Patient Imaging Procedures: Each nuclear medicine imaging procedure involved the orchestration of a suitably chosen radiopharmaceutical (i.e., a radioactive "tracer"), a suitably chosen route of administration of this "unsealed" radiopharmaceutical (by IV injection, inhalation, ingestion, etc.), and a suitable imaging technique and sequence needed to document the distribution, regional uptake, and excretion of the tracer.
The older generation imaging technology that I had been exposed to in medical school was the rectilinear scanner, and such scanners were still in use especially for imaging of high energy photons, such as in thyroid scanning using radioactive Iodine-131. However, such scanners were very slow, clumsy, mostly fixed in orientation, and very low in resolution, and became obsolete soon after I entered practice.
Fortunately by the time I entered radiology and NM, a newer technology for imaging photons emitted in vivo had come into widespread use, namely the gamma camera. It was invented in the 1950s by Hal Anger, and thus for a while was called the Anger scintillation camera. The procedures in general were termed gamma camera scintigraphy. This device became the workhorse of the NM department. The gamma camera could be pivoted into any position, with the patient also in any position, so that oblique or other special views became the norm (as in lung scanning for pulmonary embolism). By the time I entered NM, the gamma camera had been expanded in capability by interfacing with a computer system to allow more sophisticated image processing, and by combining with a moving patient table to allow scanning of regions larger than the camera's intrinsic field of view, such as in whole body bone or gallium scanning.
(In the 1980s, gamma camera imaging or scintigraphy was further improved by the increasingly widespread availability of SPECT, the acronym for Single Photon Emission Computed Tomography. This imaging modality allowed creation of "slices" through the body, analogous to computed X-ray tomography. Positron Emission Tomography (PET) imaging device was invented in the 1970s, but became widely available in clinical NM only during the 1990s and early 2000s, and has further advanced the sophistication and capability of NM imaging technology.)
Radiopharmaceuticals: The molybdenum-99 generator system was also invented in the 1950s, giving a ready source of the moderately short-lived radioisotope, technetium-99m, which gave off photons having an energy ideal for imaging with the gamma camera. Other improved radioisotopes and radiopharmaceuticals (drugs containing radioisotopes, i.e., radioactive isotopes) were also coming into widespread use by the 1970s. For instance, Iodine-131 for imaging was being supplanted by Iodine-123, which had a lower energy and more optimal gamma ray and a shorter half-life (thus causing less radiation to the thyroid gland). The formulation of suitable radiopharmaceuticals, such as Technetium-DMSA for kidney imaging or Technetium-DISIDA for liver and bile duct imaging, was steadily becoming increasingly sophisticated and specialized, and of critical importance to the development of highly selective procedures which would be taken up by specific organs or disease processes. This progress in radiopharmaceuticals has presumably continued to this day, although I am less familiar with developments since I retired.
Thyroid Therapy: A unique aspect in NM was the historical and longstanding use of radioactive iodine in the therapy of certain thyroid disorders, namely hyperthyroidism and well-differentiated thyroid cancers. These conditions were the ones most capable of taking up radioiodine for potential therapeutic benefit. NM specialists were therefore trained in the intricacies of thyroid metabolism and disease, and were generally well suited to this important therapeutic role, even though most of us (certainly myself as a diagnostic radiologist) would rarely have occasion in the future to treat conditions outside the thyroid gland. (Certain other sophisticated treatment opportunities came along subsequently in NM that I have mostly not had experience with.) Dr. Griep was quite experienced with thyroid conditions, and I continued to call on his expertise throughout my subsequent years of practicing radioiodine NM therapy—I greatly appreciated his availability and sage counsel.
Mathematics, Calculators, and Computers: This was the first time in my medical career when I found myself encouraged to make use of my mathematical background, as the understanding of underlying physical mechanisms (such as radioactive decay rates, photon attenuation, and Compton scattering) and of the instrumentation in NM drew heavily on mathematics. Moreover, this was the first medical environment I worked in that made highly visible and extensive use of computers, in particular for NM studies of the heart, such as "MUGA" (multiple gated acquisition) studies of the radioactively-labeled "blood pool" within the cardiac chambers. (I have given a detailed history of the cardiac NM studies I implemented in later years at Seattle's Providence Medical Center elsewhere, including such blood pool cardiac studies.) At a much smaller scale, I also took the opportunity to study in detail the operation of the Hewlett-Packard family of handheld scientific calculators (including the arcane mysteries of Lukasiewicz's Reverse Polish Notation). The HP-35 (released in 1972) and its successors, the HP-45 (1973) and HP-65 (1974), were marvels of compact engineering and computational capability compared to the primitive devices I used as recently as my years at M. D. Anderson Hospital in the mid-1960s, and caused the final demise of the slide rule. (K&E made their last slide rule in 1975.) Using programmable HP calculators, probably the HP65 and certainly later the alphanumeric and expandable HP-41C (released in 1979), I learned the fundamental principles of programming, including logical flow control (looping and iteration, conditional branching, etc.), for the first time in my life, though using HP's proprietary calculator language. (I would later put this skill to use in writing a program for the HP-41C that made possible certain complex and clinically useful calculations relating to obstetrical ultrasound, see here). Of course, personal computers were also becoming more available as of the late 1970s. Physicist Tom Lewellen was the first person I knew who owned or made use of a personal computer. The first Apple I model went on sale in 1976, and he probably acquired his in the same year—his intense enthusiasm inspired my early interest in this emerging technology. (My own first personal computer was an Apple II, acquired in September 1981, see here. See also here for a chronology of PC development.)
NM versus Radiology: One interesting aspect was the somewhat uneasy relationship between NM and diagnostic radiology at the time. These were, in some ways at least, separate departments at the University of Washington. Nuclear medicine arose as a specialty under the guidance and enthusiastic promotion of Dr. Henry Wagner, an internist who championed the medical uses, both diagnostic and therapeutic, of unsealed internally administered radioisotopes and radiopharmaceuticals. (This was in contrast to the implantation of sealed sources of radiation, such as radioactive iodine seeds used for prostate cancer, or the use of external radioactive sources such as Cobalt-60 for administration of radiation.) Because of its origins and the many initial procedures (such as the Schilling test for pernicious anemia) that involved administration of radiopharmaceuticals but no imaging per se, nuclear medicine originally had little relationship to diagnostic radiology. As advocated by Dr. Wagner, it evolved in departments separate from radiology, populated primarily by internists who had become nuclear medicine specialists (whom I will term "internist nucleons" for short).
However, as the imaging aspects of nuclear medicine became more predominant, and the images better and better in resolution, the obvious kinship with other imaging modalities used in diagnostic radiology (such as CT), and the need for closer anatomic correlation with these other imaging modalities, became increasingly evident. Radiologists generally knew less about the biochemical pathways and radiopharmaceutical intricacies which internist nucleons could more easily understand, while internist nucleons generally knew substantially less anatomy and regional pathology than what radiologists were used to dealing with on a regular basis. Of course there were exceptions on both sides. The melting pot was further spiced up by the existence of certain pathologists and laboratory medicine specialists who also took up nuclear medicine as a specialty. Thus the makings of an ongoing turf battle were well-established when I followed my illustrious radiologist predecessor, Dr. George B. McDonald, into the UW NM department as probably the second diagnostic radiologist to become a NM resident at the UW. I imagine Dr. Nelp was aware of the desirability of having some interbreeding between these two specialties, and for that reason among others had encouraged me to follow my interest in NM.
Board Certification in Nuclear Medicine: I was awarded Board Certification in Nuclear Medicine dated October 27, 1976 (details here).
Summing Up My Residency Experiences at the UW: My residency years at the UW had been a time of hectic and intense work, involving considerable pressure, stress, and sleep loss while juggling complex schedules including daytime patient care, night and weekend call, and conferences and lectures, as well as adapting to the many forceful and divergent faculty personalities I encountered. Although there were some parts of our program that needed improvement, especially in HMC radiology, taken as a whole the UW residencies in radiology and NM were remarkably well rounded and comprehensive. I found these years generally quite satisfying, and emerged feeling that I was at last reasonably well prepared to enter the contemporary workforce as a physician practicing in my chosen specialties. This process had taken 13 years of higher education past high school: four of college, four of medical school, and five of internship and residency (to which might be added the two more years of useful practical experience in the USPHS, thereby totaling 15 years of medical preparation). The residency years were pragmatic years filled with practical learning assignments and tasks, not a time for great reflection, contemplation, or philosophizing. I had left the practice of general medicine behind me for good, and would thereafter consider myself a diagnostic radiologist with nuclear medicine and (soon) diagnostic ultrasound subspecialization. These fields were much too complex, rapidly changing, and challenging for me to ever feel overconfident or secure in my abilities, but I looked forward to plunging into practice and doing the best job I could.
Introduction and Definitions: Although I'll have many specific things to say later about the radiology groups I subsequently practiced with, it seems appropriate to make some general comments here. This will allow me to avoid the appearance of singling out, for what might occasionally be critical commentary, any particular radiology group practice that I observed directly or indirectly (and there were many). I have not attempted to do any research in preparation for writing this section—these observations are simply based on my own experiences and impressions primarily from 1972 up until 1994 when I retired. It is likely that some things have changed since 1994 that I am unaware of, although the basics probably remain the same or have evolved as I myself have noted.
Although the Seattle radiology group that I eventually joined initially included therapeutic radiology (about which I know very little) as well as diagnostic radiology, I will confine my comments about radiology to diagnostic radiology, and will use these terms interchangeably. For convenience, I will also use in this section the term "he" when I actually mean "he/she", "him" for "him/her", etc. (Wouldn't it be nice if the English language by now provided a convenient set of short non-gender-specific singular pronouns usable in this manner!)
The practice of radiology, particularly the private practice of radiology, involves a number of conflicting demands, competing forces, and compromises. By "private practice", I am referring to practice compensation arrangements in which the radiologists are essentially self-employed (though often within partnerships or professional corporations), and are compensated at least to some degree in proportion to the fees billed for the individual cases handled (in contrast to arrangements in which the radiologists work primarily on salaries fixed and paid by employing organizations, such as in HMOs, university medical centers, governmental institutions like VA hospitals or the PHS, etc.) The distinction is not absolute, however, and there are all gradations between the two extremes (salaried versus fee-for-service), since in some practices, compensation may for instance be a combination of a fixed base salary and various bonuses for caseload productivity, research, teaching, or administrative work.
Roles Played by Radiologists: Radiologists used to be almost exclusively men, and the field tended to have a somewhat macho and stern quality, rather lacking in warm fuzziness, but by the time I entered my residency there was a reasonable sprinkling of women as well. (Apparently a disproportionately low 33% or fewer of radiology residents were female before 2012—see References for articles discussing why women remain relatively unattracted to radiology.) A diagnostic radiologist typically functions as a "doctor's doctor", since he works at the request of other physicians rather than by self-referral of patients, and, for certain types of procedures, may even have little or no direct interaction with the patient. He is exposed to and becomes quite familiar with a variety of medical conditions often encountered in surgery, pediatrics, internal medicine, neurology, orthopedics, or in the subspecialties of these fields, etc. When functioning at his best, a radiologist can be invaluable to a receptive clinician by providing—in addition to the requisite exam performance and interpretation—cross-disciplinary insights and perspectives about the disorders their patients present with, and can often help with suggestions about what to do next diagnostically and even therapeutically. (Unfortunately, radiologists tend to be relatively unfamiliar with medical conditions that have few if any radiological manifestations.) Because we mostly work at the request of other physicians, our clients, the referring doctors, are a very demanding and highly critical bunch, expecting us, for example, to drop whatever we are doing in order to address their requests and concerns. (I accepted this aspect of practice gracefully.)
As a radiologist, my professional allegiance remained first and foremost to the venerable profession of medicine as a whole. Allegiances to my subspecialties, my parent specialty of radiology, my group practice, my hospital, and my medical community were in my opinion subordinate (and in about that order). Put another way, I have always tried to keep focused on the ethical principles of the practice of medicine as a whole—and thus ultimately the needs of my patients—and not just on what seemed best for radiology or my group.
The "Good Old Days" of Radiology: Radiologists were once an especially peculiar and rare breed within the practice of medicine. Formerly practicing in relative obscurity, hidden behind red goggles and wearing heavy lead aprons in darkened rooms, they emerged from the shadows of medicine when the goggles were no longer needed, and radiologic technologies became so spectacularly good and informative that they became more integral to many medical workups, essential even for the rapid evaluation of acute medical conditions. In the old days, again well before I entered radiology, the field had the reputation for having banker's hours and reasonably high monetary compensation, though with increased risk of death due to occupationally-acquired radiation effects such as leukemia (a relative risk which has apparently decreased substantially). Radiologists worked hard during the weekdays, but often had ample time off and would, at least in many practices, allow a stack of films (plain radiographs) to accumulate through the weekend, coming in to interpret ("read") them on Monday morning. (This was especially the case in small town practices, where the workload was modest and/or there were few competitive pressures.) There was thus an uncomfortably schizophrenic attitude about how important the procedures were: they were important enough to be paid well for them when finally performed and/or finally interpreted, but not necessarily so important as to justify coming in at night or on the weekend.
Timeliness of Exams and Availability of the Radiologist: By the time I trained in radiology, new practice conditions and perceptions were relentlessly forcing on radiologists a more attentive and consistently timely approach. In particular, more radiology exams took on such importance in the diagnostic evaluation of emergency conditions that performance and interpretation of the exams could no longer comfortably be deferred to the next weekday. These included CT brain exams to differentiate ischemic from hemorrhagic stroke, cervical spine X-rays to look for acute fracture, IVPs to detect kidney stone in the ureters, myelograms looking for acute spinal blockage, pelvic ultrasounds looking for placenta previa in a pregnant patient with bleeding, lung NM scans looking for pulmonary embolism, renal NM scans looking for acute transplant rejection, and many others.
The rising costs of hospitalization were also a factor in forcing more timely performance of radiology procedures, since each day that the evaluation of an inpatient was delayed added considerably to the costs of the hospitalization.
It was thus becoming increasingly apparent that the radiologist needed to be prepared to provide his services 24 hours a day, seven days a week. During my years in practice, most practices that lacked residents available to help take call resisted actually placing a radiologist "in house 24/7" to meet the radiology needs, but the radiologist was required to be readily available on call. In my own practice in Seattle, just before I stopped taking call in 1990, it was not unusual to be called in for emergency procedures four or five times in one night.
Unfortunately, my final years of participating in on-call work just preceded the era when remote exam evaluation and interpretation by computer-enabled "teleradiology" was readily available. This technology has substantially eased the burden on the contemporary radiologist, though many emergency procedures still require his on-site presence. I suspect that some radiology practices, especially in the largest or most academic hospitals, have evolved into having a radiologist or radiology resident stay in-house 24/7. This would seem in some ways to be the ideal, though the decision is complicated by the presence of subspecialization in larger practices, so that not each radiologist would be expert at performing any and all procedures offered by other radiologists in the practice. Each practice must therefore work out for itself how it will compromise on the 24/7 in-house ideal, typically resorting to a combination of prolonged in-house hours, teleradiology including employing distant consultants, and various subspecialized members coming in as needed for emergency procedures.
Competition and Economic Pressures: Another factor that has contributed to the pressure on the radiologist to offer 24/7 hospital services in some form, and which in general has greatly increased the stress of contemporary radiology practice, is the ever-increasing competition from other practitioners, including other radiologists and also non-radiologists (particularly in highly desirable cities such as Seattle).
It is a fact of life for radiologists that they typically have no faithful patients of their own. (We rarely received Christmas gifts from our grateful patients on whom we had performed barium enemas or myelograms!) Instead, we practiced at the mercy of our referring clinicians, who could and often did choose to refer the patient for examinations to other radiology facilities (unless the patient was hospitalized in the hospital in which we happened to practice).
Over the years, the performance and/or interpretation of certain diagnostic procedures has also more and more shifted out of radiology control and into the hands of competing specialties: ultrasound by obstetricians, bone densitometry and thyroid therapy by endocrinologists or internists, coronary artery interpretation and nuclear cardiac imaging by cardiologists, peripheral angiography and needle biopsies by surgeons, etc. This has especially been the case in tight job markets such as Seattle, in which an oversupply of clinicians compete for relatively scarce patients. Such trends to transfer radiology into the hands of non-radiologists were in my opinion not typically in the best interests of the patients.
The only reasonable response to such competitive pressures by the radiologist (as opposed to hiring a hit man to deal with the offending competitors) was to try to keep fees competitive and to be the very best and most skilled practitioner of the procedure, and to hope that meritocracy and a high level of service would win the day. Sometimes, compromises in such "turf" battles could be worked out with the help of the medical director or other official of the hospital. More often than not, however, radiologists tended to lose in these confrontations, since other physicians were relentlessly and increasingly attracted to the relative high monetary compensation granted for procedural medicine (and if they did not get their way, they would often establish competing radiology services which they controlled in their private clinics).
The pressure was on radiology groups to provide their best subspecialist for such competitive procedures, but staffing conflicts and logistical problems could sometimes prevent this and were a constant cause of stress and rising tensions among the radiologists. In some cases, the non-radiologist could indeed perform a radiology procedure with greater skill, safety, efficacy, or patient convenience than the radiologist could—though this seemed to me to be very rare. (In fact, as an example, I often politely endured assisting an unskilled clinician perform a biopsy by providing to him ultrasound guidance, so that he could collect the procedure fee, even though we both knew that I could likely have performed it myself with significantly greater accuracy, speed, and safety.) Almost without exception, non-radiologists providing radiology-like services rarely offered reduced fees for the benefit of their patients—they wanted those fees.
Insecurity of Radiology Contracts: For hospital practices (as opposed to private office practices), radiologists typically strived to secure exclusive contracts to provide radiology exam performance and interpretation. Such contracts were essential in order for the group practice to be able to determine its staffing and scheduling needs, to plan for gearing up to handle evolving technologies, and to be able to compete fairly against the practitioners who controlled the referral of patients. However, these contracts (which were often only vague and/or oral understandings) became increasingly elusive, restrictive, and problematic to obtain and to maintain. The hospital would often demand increasing concessions from the radiology group, as might be expected in increasingly competitive environments, and the contracts could be rescinded on short notice.
The hospital practice component of a radiology group practice was often the most important and far-ranging part of the practice, but we practiced in any hospital solely at the discretion and whim of the hospital administrator, and some of them could be Machiavellian in their dealings. Having physician staff privileges to practice radiology in a hospital—the same privileges defined by bylaws and enjoyed by other physicians in other specialties—turned out to provide little additional job security, since the hospital could effectively terminate a group's in-house participation in radiology simply by transferring the exclusive contract to another competing group of radiologists. We thus lived in fear of such arbitrary and capricious actions by hospital administrators. The same fear applied to our contractual relationship with various clinic radiology services, where again we practiced solely at the discretion of the administrators and physician committees directing these clinics—such abrupt terminations from providing clinic radiology services did in fact happen to my Seattle group practice. In short, it was a real jungle out there, and radiologists had good reason to be a little paranoid!
Private Radiology Office Practices: Most large radiology group practices also had a private office practice to fall back on, separate from the clinics and hospitals where they could be readily terminated. The private office practices offered the radiologist the opportunity to be a truly independent practitioner, just like any other office-based medical specialist or dentist. During my years in practice, I saw radiology private offices enjoying varying degrees of success, ranging from apparently moderately successful and presumably remunerative ones to others which were just barely squeaking by or were actually losing money (and therefore subsidized by the hospital components of the group practice). The radiology equipment was increasingly complex and expensive to own and operate, the staffing needs were considerable, and the overall financial risk was high. Unless the office practice was successful in establishing adequate referrals from clinicians (who could after all refer elsewhere), the office practice would likely lose money.
Compensation and Perquisites: It is a singularly uncomfortable aspect of medicine in general to contemplate that we doctors must make money off the medical disorders and sometimes effectively the suffering of our patients—especially if we bill for our individual services rather than just being salaried. It is therefore essential for us to remain professionals dedicated to the ideals of medicine, particularly the ideal that such compensation should always be justifiable. I often told myself, my colleagues, and my business manager that I wanted to be able to set fees for the procedures that I managed (such as in nuclear medicine and diagnostic ultrasound) at levels that I did not feel were exploitive and that, as I expressed it, I would feel comfortable discussing while sitting across a kitchen table from a patient. However, fees tended to be established along "usual and customary" guidelines, and the economic forces at play in a group practice, including the adverse factors expressed above, resulted in little latitude for downward adjustments of fees out of conscience. (Of course, I benefited along with my colleagues from fees set at higher levels.) Moreover, the amount that radiologists actually receive for their services from third-party payers such as Medicaid, Medicare, or Regence BlueShield are often, as with hotels, much less that their "rack" rate, and negotiated contracts (over which the radiologists have little choice or control) prevent them from "balance billing" the amount of the imposed discount.
Compensation tended to be higher for private practice fee-for-service radiologists than for salaried radiologists, though there were certainly many exceptions on both sides. It was also a goal of private practice to have greater autonomy in scheduling, allowing in some cases a more flexible approach to time off and vacations.
During my years in private practice, I found that we were generally well compensated as radiologists for our hard work, in some circumstances appropriately for the amount of effort and training involved, but probably too well compensated for certain other procedures, given the smaller amount of time that at least some radiologists devoted to the task, or the relatively low expertise required or applied.
Broad Range of Uncompensated Services Rendered: Of course, our involvement in any particular procedure often went well beyond the initial act of exam performance, supervision, and interpretation. We could be repeatedly called upon subsequently by various clinicians to discuss the case, and to make recommendations for follow-up, particularly as more information about previous exams or new developments became known; or we might choose on our own to research complex aspects of the case to improve our understanding about the findings; or we would often be called upon to present aspects of the case at the various working or didactic conferences we were expected to attend; or, in one of the more dreaded worst-case scenarios, we might be required to defend ourselves in threatened or actual malpractice actions pertaining to the procedure. In my Seattle practice, at least, we also willingly took on the uncompensated role of teaching medical students and house staff, just as we were instructed to in the Hippocratic Oath. In private practice, radiologists such as myself spent a considerable amount of vacation and weekend time, personal funds, and energy trying desperately to keep up to date with the rapidly evolving procedures and technologies by attending scientific conferences and courses, often given out of town and therefore at considerable expense. Finally, as part of our uncompensated responsibilities assumed as part of our hospital affiliations, etc., I like other radiologists in my groups spent a considerable amount of time serving on various hospital committees.
"Procedural" versus "Cognitive" Physicians: There has been a long-standing discrepancy in private medicine in which physicians who work hard and perform many procedures tend to be relatively well-compensated, while those who work perhaps equally hard but have mostly non-procedural dealings with patients—such as primary care physicians who perform history and physicals, develop treatment plans, and monitor therapy—tend to be less well compensated. (Since the latter were often termed "cognitive" physicians, I have mused that radiologists, being mostly procedural physicians, might in some circles and by implication be termed "non-cognitive" physicians.) Though I am not at all well informed about recent trends, I suspect the income gap between procedural and non-procedural physicians has tended to narrow further since I retired, especially through the workings of Medicare and other powerful third party payers, etc., but I doubt the gap is anywhere near being closed, at least with respect to radiology practices. (Of course, physicians who are salaried by HMOs, the government, or university medical centers, etc., do not face this income discrepancy to quite the same degree.)
Radiologist Subspecialization, Skill Levels, and Seniority: One of the more sensitive and problematic issues in radiology group practices was how to accommodate the varying levels of skill and subspecialization among the members. For example, it sometimes seemed to be case that older members in a group practice tended to allow themselves to fall behind in keeping up with rapidly evolving technologies. They were to some extent placed at an unfair advantage compared to the younger radiologists who were fresh from intensive training experiences in these technologies, and/or were more aggressive or energetic. (The very youngest members of a group were typically less experienced overall, but they were also usually compensated at a reduced level, ostensibly reflecting their lower experience and value to the group.)
It was often argued that, in addition to their sheer seniority, the older members of a group brought years of valuable experience to the intragroup negotiating table, but in a rapidly changing practice environment heavily involved with complex new technologies, the value of this senior experience was sometimes marginal or not as high as they hoped. Moreover, the stress levels and time demands were much higher on the less senior members who were actively developing and implementing these newer technologies. The older members also typically had more resources available at their disposal, both in vacation time and income, in order to seek additional training.
The question the group often faced then was, would the older and more senior members put out the effort and consume their own (usually greater) resources to seek such training? (In my experience, all but the most enlightened private radiology group practices were reluctant to subsidize to any great extent its individual members in seeking additional training. This lack of subsidization was characteristic more of private practice groups than salaried environments such as university departments.) Some of the more highly motivated older members would make serious attempts to do this, but others would opt for complacency, keeping a low profile, and trying to confine their work to less intensive and less challenging areas of the practice that they felt more comfortable with.
This tendency of
older members to become less capable than the younger ones with respect to
the broad gamut of procedural requirements of the practice bred conflict,
especially when the younger and possibly more skilled members were receiving
lower pay due to the group's compensation formula. There was no easy
solution to this problem, and responses by the older and more senior group leadership
could and sometimes did include:
(1) keeping dictatorial and undemocratic control on the voting structure, in order
to prevent threats to their tenure from younger members;
(2) threatening or
firing younger members who acted too aggressively or complained too much about
such practice shortcomings and inequities;
(3) ensuring that their own presence remained positive for the group by actively cultivating and maintaining practice
niches that contributed significantly to the health of the practice, and providing essential, enlightened, and skilled leadership; and
(4) working hard at ensuring and
maintaining well-balanced and equitable work loads, and actively seeking additional training as
needed such that they did not in fact become obsolescent within the practice.
Of course, I favored items (4) and (3), in that order, as the most ideal approach for keeping a
group practice equitable, viable, competitive, and successful. I emphasize that this discussion does not single out any particular group practice with which I was familiar, but encompasses the entire gamut.
Exam Quality and Real-time Supervision versus Productivity: Another consistent point of tension in group practices was the issue of individual productivity versus quality, thoroughness, and specificity of procedures. Some procedures, such as angiography, require the undisputed presence of the radiologist, whereas a few are routinely performed without the radiologist's presence and direct supervision (such as portable chest X-rays), but there is a large body of procedures falling in between regarding the need for real-time supervision or participation. As an early example, I was trained under Dr. Leon Philips to perform customized X-ray IVP's, such as were advocated by Dr. Anthony Lalli in his esteemed 1973 textbook, The Tailored Urogram. This meant that the radiologist supervising such an exam had to be available to view each carefully timed film as it came out, in order to request appropriately customized additional views as needed. The radiologist could therefore not leave the area where the exam was being performed (perhaps for the purpose of conducting other procedures) until the IVP was completed. (Some of this pressure has undoubtedly been alleviated in contemporary radiology practices fortunate enough to have real-time availability of networked digital images for exams in progress, so that the images can be reviewed from remote sites for the purpose of suggesting additional time-sensitive views. Such networks were unfortunately not available in my practice settings while I was in practice.)
For many reasons, there was a relentless pressure in groups to streamline procedures by making them proceed according to a canned or cookbook approach without real-time hands-on radiologist supervision, but conscientious radiologists (such as I considered myself) often felt that a cookbook approach involved excessive compromises on the quality and specificity of the exams, and left the patients suboptimally cared for.
Similar tensions and conflicts occurred in the performance of various nuclear medicine procedures, especially radioiodine therapy for thyrotoxicosis or cancer, and in diagnostic ultrasound exams, especially OB ultrasound exams. The question often arose, for example: Was it sufficient for the sonographer (ultrasound technologist) to perform an exam and record it on videotape and on films for later review by the radiologist at his convenience, or did the radiologist need to be present real-time while the exam was in progress in order to interact with and modify or improve the exam? In my considered opinion, it was always highly desirable for the radiologist to be present for review and refinement of the OB ultrasound exam, often by his directly passing the ultrasonic transducer over the patient, and this was my personal policy throughout my practice years. But personal practice policies such as this created stress and conflict if my schedule attempted to place me elsewhere performing other procedures or attending teaching conferences, in order to gain maximum use of my time and availability, while ultrasound exams I was supervising were in progress.
I trust the discussion above helps to convey some of what makes the practice of radiology so complex, challenging, and at times remarkably stressful, no longer like the "Good Old Days", but still quite gratifying in its value to patients.
As I neared completion of my training in NM and as a result of a great deal of hard work, I found that I had generated a reasonably good professional reputation, felt fairly confident about my skills, and was fortunate to be offered a number of appealing job opportunities.
Academic Medicine versus Private Practice: I was now faced with the decision whether to remain in academic medicine (in the UW system) or to venture forth into private practice. Such a decision was not irrevocable, as I knew many radiologists who went from academia to private practice, as well as a smaller number who went in the opposite direction. (Now it seems to be more common to go from private practice back to academia.)
Seeking Professional Growth: One perception I had was that I did not wish to enter a practice that would offer only limited opportunities for professional growth and development. This was because radiology and nuclear medicine were rapidly advancing, and looking into the future, I feared the possibility of gradual professional obsolescence and personal dissatisfaction if I did not make vigorous efforts to keep up with the field, and work within the fullest possible gamut of available techniques.
Job Offer in UW Nuclear Medicine: During my R5 year as a nuclear medicine resident, I was pleased to be offered a subsequent staff position by Dr. Nelp in nuclear medicine within the University system. I gave it serious consideration, since this was probably as good an offer in academia as I would be able to find, and the prospect was quite appealing in many respects. However, it seemed to me that I would put my hard-won radiology and NM skills and training to best use by finding a position in a diagnostic radiology department which included nuclear medicine as a tightly integrated section (or at least which worked closely with NM). I was also wary of UWMC politics, which I had observed as a radiology resident to at times be vicious and Byzantine in their complexity. I felt that I simply might not prove to be sufficiently nimble or politically savvy enough to navigate successfully these treacherous shoals.
Moreover, the UW at the time had a rigid publish-or-perish requirement for its physicians, and back then did not make room for purely clinical practitioners such as I wished to be. I doubted that I would have what it took to crank out the steady stream of successful research papers needed to win tenure. (Fortunately, in recent years, UW radiology has wisely begun to offer purely clinical track work-in-the-trenches positions to a few radiologists, in addition to the tenure track positions.)
The salary differential was also a consideration, but not as great in importance to me than to some. For all these reasons, I opted not to take the excellent offer, though in many respects I would probably have enjoyed staying in the university atmosphere—for instance, I enjoyed teaching and always had a somewhat academic bent.
I did not even attempt to explore the possibility of finding a radiology position per se in the University system, since it would presumably lack the desired NM integration, and would equally suffer from the other shortcomings just mentioned.
Job Offer in Private NM + US in Seattle: In the private practice realm, I was also given a nice offer to join the thriving group at Swedish Hospital that did solely NM and diagnostic ultrasound. Unfortunately, this also would have precluded my practicing other aspects of radiology, and I reluctantly turned it down.
(In retrospect, opting to take on a more purely subspecialized practice such as Swedish NM+US or UW NM might well have suited me better than the route I ultimately chose, though it is hard to know for sure.)
Job Offer in Private Radiology in Seattle: I was also offered an excellent job in November 1975 at another of the major private practice groups in Seattle, one where I had moonlighted and which offered just the kind of diverse practice experience including NM and US that I believed I was looking for. Unfortunately, I perceived that it had one serious flaw: the triumvirate of senior partners in the group held a permanent majority vote, regardless of the number of partners— thus a kind of "benign despotism"—and I felt this anti-democratic arrangement might prove intolerable, especially since they acknowledged they had no intention of giving it up. Although we spent a fair amount of time courting each other, and I would have otherwise found the practice quite desirable, I ultimately turned it down.
I also interviewed with some of the group members at Providence Medical Center in Seattle in August 1975, but that group had not yet reached a consensus that they needed another radiologist.
Jobs Offers Outside Seattle: I considered several other interesting offers arising in the western Washington region. And my Alaska experiences led to a tantalizing offer from from Dr. Coyle to join the radiology group at Providence Hospital in Anchorage.
Bellingham Job Offer Accepted: However, I finally decided to take the position which seemed most likely to fulfill my professional hopes and expectations, namely a job with the private practice group of diagnostic radiologists serving Bellingham, Washington. I had met with Dr. Robert Rose (who was recruiting for that group), beginning in October 1975, interviewed in Bellingham in November and December, and made a final decision by December. I describe the details and merits of this position here.
Preparing for Bellingham: Not wishing our next home to be rented, we began hunting in Bellingham in January 1976 for our first house to own.
I also began making the rounds in Bellingham, meeting the administrators at the two hospitals there, making preparations to join the Whatcom County Medical Society, introducing myself to the office staff, and completing employment negotiations.
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(8) Tovah Bender, "Kinship" The Oxford Encyclopedia of Women in World History. Oxford University Press, 2008, accessed online 31 March 2009. See also the OED.
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