The Risk Aversion Tax

I'm naturally risk averse. Most radiologists are. You can't survive premed, medical school, and residency without learning to color inside the lines. Every test you ever took rewarded the safe answer. Every attending you trained under rewarded the careful read. Two decades of training quietly drilled into us that the smart move is the conservative one.

The problem is that what's risk-averse in the reading room is not the same thing as what's risk-averse in your career. And almost nobody talks about that.

Section 1 Salespeople know. Doctors don't.

Salespeople know it. Software engineers know it. Bankers know it. There's a well-worn finding in the business world that people who change jobs every few years tend to out-earn the ones who stay put. Cameron Keng made the case in Forbes over a decade ago, arguing that staying in the same job longer than two years can cost you roughly 50% in lifetime earnings. The payroll data backs the direction of that claim, if not always the exact figure. ADP, which tracks millions of workers every month, has shown job-changers consistently out-earning job-stayers for most of the past fifteen years. As of late 2025, job-changers were still running about two points ahead — roughly 6% annual pay gains versus about 4.4% for stayers.

It's worth being honest about the caveat, because it's actually instructive. In 2025, in a soft labor market, that gap didn't just shrink — for about six months it briefly inverted, with stayers edging ahead of switchers in the Atlanta Fed's Wage Growth Tracker for the first time since 2010. By early 2026, switchers were back on top, but by a slim margin. A sustained inversion like that has only shown up around the dot-com bust and the Great Recession — moments when fear, not opportunity, drove decisions. That's the tell: the crowd stops moving precisely when it feels scariest to move.

And notice what none of that data actually measures — hourly workers and general labor, not board-certified radiologists. Our market looks nothing like the average, and as I'll get to, the radiology-specific numbers make the case far more strongly than any national wage tracker.

Doctors didn't get the memo either way. We were trained the opposite direction. Stay. Be loyal. Don't rock the boat. Wait your turn for partnership. Get tenure. There's a whole cultural script around the physician career that quietly costs us money. More importantly, it costs our families.

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

Here's what I want you to internalize. As a board-certified radiologist, you are the single most valuable asset in any radiology company you work for. By a wide margin. The PACS license is cheaper than you. The biller is cheaper than you. The CEO does not generate a single read (unless he's a reading radiologist too). You do. Everything else in the business is built around your output.

And in 2026, with an entrenched radiologist shortage, imaging volumes growing 3 to 4% a year, and a training pipeline that isn't keeping up, you have more leverage than radiologists have had in a generation. In tight markets, hospitals are paying $25,000 to $75,000 signing bonuses to convince you to come on as a W2 for a large corporate entity. Teleradiology compensation has converged with traditional private practice, and in some cases surpassed it. The market is begging you to move.

And most of us never do. We stay. We accept the schedule we were given. We never seriously model the W2 vs. 1099 math. We don't entertain leaving hospital-based work for tele (or, far more rarely, the other way around) because we ask ourselves: what if it doesn't work out?

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

Let me say it more directly. The downside you're imagining is asymmetric, and it's not nearly as bad as you think. There is a radiology job available to you in pretty much any city in this country, today, by lunchtime.

The worst case when you switch is this: I try the new gig, it stinks, I take a different one, and I lose a few months. That's not a catastrophe. That's a bad Tuesday on a five-year horizon.

The best case is more money, better case mix, less night call (or none at all), more time with your kids, a shorter commute (or zero commute), geographic freedom, and lower taxes. (If you're weighing Puerto Rico and Act 60, ask me — but talk to a tax professional who knows the residency rules before you count on any of it.) The best case happens more than you'd think: all of the above, at once.

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

I'll be upfront: I run a teleradiology group and I hire radiologists, so I have a stake in this. Read accordingly. But the math is the math, and it doesn't care who's writing.

I've interviewed hundreds of radiologists, and I hear their stories. One took a Veterans Administration (VA) job because his wife wanted him to have benefits. The VA caps a physician's total compensation so it can't exceed the President's salary — $400,000 in 2026. (A 2025 law now allows the VA to grant a limited number of waivers above that cap, but the department has been slow to implement them, and most VA rads still hit the ceiling.) His family is losing hundreds of thousands of dollars a year.

I hire former VA rads who are sick of hitting their quota in April or May, then effectively working for free for the government the rest of the year while still having to show up. Their generosity gets taken for granted. Same story for hard-working younger partners on a five- or eight-year partnership track where the goalposts keep moving. And sometimes the goalposts just disappear: partnerships fold, lose hospital contracts, or get carved up and sold to private equity right before the radiologist makes partner, leaving them high and dry. That's the part people invert — working for yourself across several clients can actually be more secure than a single W2 job, where one employer owns your entire income and can end it in a day.

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

It's the dinners you miss because you're stuck reading at 9 PM on a workflow that doesn't suit you. It's the case mix that grinds you down because you didn't want to renegotiate. It's the vacation you didn't take because the partnership track frowns on it. It's the call you take every other weekend. It's the resentment your spouse swallows quietly for years.

I've said it before in my Guide to Being an Efficient Radiologist: choose your partner well, and then take care of them. Most of us would say our family is the reason we work as hard as we do. And then we make career decisions as if our families don't exist. We stay in a job we've outgrown because change feels risky — even when the cost of not changing is being a less-present parent, a more-stressed spouse, and a less productive, less happy version of ourselves.

Section 6 A small framework for deciding.

When I'm trying to decide whether to make a change, I run four questions. Take ten minutes. Write the answers down. Don't just think about them.

Write down the worst case. Be honest. Usually it's: "I try the new gig for 90 days, it stinks, I take a different one." That's not a catastrophe. That's barely a blip in a career.

Write down the best case. Run the math. Your true hourly rate after accounting for commute, time getting dressed, admin time, and hassle. Pay per unit of effort. Flexibility. Case mix. Hours per week. State tax exposure. Total take-home. And the one people skip: hours saved — because hours are time with your kids.

Ask your spouse. Not "should I do this." Ask: "Would our life be better in scenario A or scenario B?" You'll be amazed what your partner has been thinking and not saying. Keep in mind, though, that in my experience most spouses are even more risk averse than their radiologist partners.

Spend some time with Claude. Ask it about the advantages and disadvantages. Have it help you calculate your hourly rate after every expense, time-suck, and headache. Notice the decision is rarely close once you've written it down and analyzed it.

Radiology rewards careful readers. The job demands it. But careers reward people who are willing to move when it makes sense. Most of us never do. And the cost of that doesn't show up on a spreadsheet. It shows up at the kitchen table. And your family is sitting there, waiting for you.

That's the version of the cost that matters.

Written by

Avery J. Knapp Jr., M.D.

Founder, Board Certified Radiologist