Risk Aversion Is a Tax, and Your Family Is Paying It

I'm naturally risk averse. Most radiologists are. You cannot survive premed, medical school, residency, and years of attending-level scrutiny without learning to color inside the lines. Every test rewarded the safe answer. Every attending rewarded the careful read. Two decades of training quietly taught us that the smart move is the conservative one.

That instinct is useful in the reading room. It is not always useful in your career.

The problem is that radiologists often carry diagnostic risk aversion into career decisions where the math is completely different. In a report, caution can protect the patient. In a career, caution can become a tax. And too often, your family pays it first.

Section 1 Salespeople know. Doctors don't.

Salespeople know it. Software engineers know it. Bankers know it. In the business world, there is a familiar argument that people who change jobs every few years often out-earn people who stay put. Cameron Keng made the point sharply in Forbes more than a decade ago, arguing that staying with the same company longer than two years can cost a worker a large share of lifetime earnings [1].

That exact number is not a radiology-specific law of nature. It depends on the person, specialty, market, starting point, and timing. But the direction of the claim is not hard to find. ADP's December 2025 Pay Insights showed job-stayers at 4.4% year-over-year pay growth and job-changers at 6.6% [2].

There is an important caveat, and it actually teaches the lesson better. In 2025, a softer labor market briefly narrowed and even inverted the job-switcher premium in the Atlanta Fed Wage Growth Tracker, with stayers edging switchers in July before switchers moved back ahead in August [3]. When labor markets cool, people stop moving. Fear gets louder. Offers get thinner. The crowd becomes more cautious exactly when decisions feel most uncomfortable.

But notice what those national data sets do not measure. They do not measure the market for board-certified radiologists, with rising imaging volumes, constrained training supply, and facilities trying to keep coverage intact.

Doctors did not get the memo anyway. We were trained the opposite way: stay, be loyal, do not rock the boat, wait your turn, keep grinding. There is a cultural script around physician careers that quietly costs us money. More importantly, it costs our families.

Section 2 You are the most valuable asset in the building.

Here is what I want radiologists to internalize: as a board-certified radiologist, you are the scarce asset in the system. The PACS license does not generate the read. The billing system does not generate the read. The spreadsheet does not generate the read. You do.

That does not mean every job is good, every offer is fair, or every career move is wise. It means your default should not be passive acceptance. If a practice, hospital, group, or teleradiology company builds its business around your output, then you should understand your leverage with the same seriousness you bring to a difficult case.

The workforce backdrop matters. ACR's 2026 HPI workforce update describes a field managing high imaging volumes that have grown faster than the number of radiologists [4]. Recruiting data tells the same story from a different angle: radiologists remain among the most requested physician specialists, with meaningful signing bonuses and incentives appearing in the market [5].

And most of us still do not model the decision. We accept the schedule we were given. We never seriously compare W2 versus 1099 on actual take-home, actual hours, actual call, actual commute, actual administrative friction, and actual family time. We do not consider leaving hospital-based work for tele, or leaving tele for a better local role, because the first question is: what if it does not work out?

Section 3 "What if it doesn't work out?" is not the real risk.

Let me say it directly: the downside you are imagining is usually not symmetrical with the upside you are ignoring.

If you are a strong radiologist, the worst realistic case is often not catastrophe. It is trying a new model, discovering it is not right, and moving again. That is annoying. It is disruptive. It is not nothing. But on a five-year horizon, a few uncomfortable months may be smaller than the cost of staying in a role that has already stopped working.

The best case is not only more money. The best case is better case mix, less call, more control over your workday, no commute, geographic freedom, fewer missed dinners, and a career structure that is actually compatible with the family you say you are working for.

There can also be tax and entity-structure implications, especially when comparing W2 and 1099 work or evaluating a move to Puerto Rico. Do not wing that. Talk to a tax professional who understands physician compensation, business structure, residency rules, and the specific facts of your life before counting on any tax outcome.

Section 4 I have interviewed hundreds of radiologists. The same story keeps repeating.

I will be upfront: I run a teleradiology group, and I hire radiologists. I have a stake in this conversation. Read accordingly.

But the stories are not imaginary. I have interviewed hundreds of radiologists, and I keep hearing versions of the same thing. Someone chose the safe job because the benefits felt comforting. Someone stayed on a long partnership track because leaving felt disloyal. Someone accepted every-other-weekend call because that was the deal when they arrived, even though the rest of their life changed. Someone kept waiting for a future that the group quietly moved farther away.

Sometimes the risk they were avoiding was real. Sometimes it was just familiar. Those are not the same thing.

A single W2 job can feel secure because one employer sends one paycheck. But concentration is also risk. One employer owns your entire income. One leadership change, one contract loss, one private equity sale, one compensation redesign, and the safe thing may suddenly look less safe. Working across multiple clients or in a carefully built independent model can be more resilient than many radiologists assume, provided the structure is sound.

That last phrase matters: provided the structure is sound. Do not confuse movement with strategy. A bad 1099 setup is still bad. A chaotic teleradiology job is still chaotic. A higher headline number can vanish if the schedule, malpractice terms, benefits, taxes, and workflow are wrong. The point is not to jump blindly. The point is to stop refusing to look.

Section 5 The cost of staying isn't on your paystub.

The cost is the dinner you miss because you are still reading at 9 p.m. on a workflow that does not suit you. It is the case mix that grinds you down because you did not want to renegotiate. It is the vacation you never took because the partnership track frowned on it. It is the call schedule your family silently built their life around.

Most of us say family is the reason we work so hard. Then we make career decisions as if our family does not exist.

If a job has become a bad trade, your spouse and kids usually know before you admit it. They see the late nights. They hear the tone in your voice. They notice when you are physically home but mentally still in the list.

That is why "risk aversion" is too polite a phrase. In many radiologist careers, risk aversion is a tax. It is paid in money, but also in presence, energy, patience, sleep, and optionality.

Section 6 A small framework for deciding.

When I am trying to decide whether a career move makes sense, I want the decision out of my head and onto paper. Take ten minutes. Write the answers down. Do not just think about them.

• Write down the worst case. Be specific. What happens if the new role is not right after 90 days? How much income is actually at risk? What contracts, notice periods, credentialing timelines, or non-compete terms matter?
• Write down the best case. Model compensation, hours, call, commute, admin time, case mix, flexibility, tax exposure, benefits, malpractice, retirement contributions, and total take-home. Then model hours saved, because hours are family time.
• Ask your spouse a better question. Not "should I do this?" Ask, "would our life be better in scenario A or scenario B?" That invites a family-level answer instead of a fear-level answer.
• Use an AI assistant or spreadsheet as a forcing function. Have it compare the actual numbers and assumptions. You do not have to obey the output, but you should make the hidden tradeoffs visible.

If the decision is still close after that, fine. Some decisions really are close. Stay if staying is the best trade.

But if the math is not close, do not let a vague feeling of safety overrule the evidence. Radiology rewards careful readers. The job demands it. Careers reward people who are willing to move when the facts say movement is rational.

The cost of staying does not always show up on a spreadsheet. Sometimes it shows up at the kitchen table.

And your family is sitting there, waiting for you.

Written by

Avery J. Knapp Jr., M.D.

Founder, Board Certified Radiologist