Radiology as a medical specialty is at the pinnacle of success. It has become essential in the practice of medicine, as it is at the forefront of diagnosis, is unrivaled in providing data for the selection of appropriate therapy, and is one of the best methods of evaluating a therapy’s success and providing follow-up. Yet in spite of these unquestioned achievements, the specialty is facing what appear to be insurmountable problems: Increasing costs vs flat or decreasing income, rapidly rising clinical load with static manpower. Need for expensive equipment and specialized staff within organizations that are in financial straits. And then there are continuous turf battles on many fronts. The resulting malaise is affecting the whole radiological community and there is a clamor everywhere for strong and inspired leadership.
Axis Imaging News is to be congratulated for focusing this issue on the problems of leadership in all of radiology, private as well as academic, and assembling an impressive spectrum of leaders to discuss the subject, from chairmen and radiologist-deans to presidents of large private radiology groups and a young prospective leader who is choosing the MBA route to leadership.
Their views provide diversity in approach and show that strong leaders do not necessarily have to possess a uniform background, but do need integrity, courage, vision, expertise in communication, dedication to improvement, business acumen, and experience. They should also be a role model. With all these requirements, it is a miracle that there still are a few great leaders in the field.
The questions of the editors are challenging, and, when all the answers are reexamined, one must conclude that the many approaches to prepare, select, and support leaders in difficult times eventually bring some remarkable wins, some failures, and yet the show goes on.
Alexander R. Margulis, MD
Weil Medical College of Cornell University
New York City
Roundtable participants include:
- Jonathan W. Berlin, MD, is assistant professor of clinical radiology, Evanston Northwestern HealthcareNorthwestern University, Evanston, Ill. He is currently enrolled in an MBA program at Northwestern University’s Kellogg Graduate School of Management.
- Howard B. Kessler, MD, is president and CEO, Pennsylvania Radiology Group, Philadelphia.
- Andrew W. Litt, MD, is vice chairman, Department of Radiology, New York University School of Medicine, New York.
- Patrick C. Malloy, MD, is chair, Department of Radiology, Danbury Hospital, Danbury, Conn.
- Lawrence R. Muroff, MD, is clinical professor of radiology, University of Florida and University of South Florida Colleges of Medicine, and president, Imaging Consultants Inc, Tampa, Fla.
- Martin L. Silbiger, MD, is professor, Department of Radiology, and professor, Department of Interdisciplinary Oncology, University of South Florida, Tampa. He served as chairman of the Department of Radiology at the University of South Florida Medical School, and subsequently was named dean of the medical school.
Q:Is today’s shortage of leaders unique to radiology?
SILBIGER: This is typical in all areas of medicine.
BERLIN: I think that the dearth of leadership in radiology is only part of a larger problem, which is the shortage of leadership in medicine in general. The most likely reason for this is the perception, widely held by young physicians, that a leadership career is devoid of satisfaction. Younger physicians are too often exposed to older physicians’ pining for the good old days before managed care and increased economic pressures, and they translate these sentiments into general feelings that medicine now is just a job, not a way of life. Because of this, younger physicians desire a more regular schedule and do not appreciate the satisfaction that comes from giving back to one’s profession in a leadership capacity.
KESSLER: Leadership in radiology may be a luxury that few groups are willing to invest in; a shortage of radiologists and ever-increasing workloads may preclude expending the time and effort necessary to develop and empower leaders. There will always be individuals willing to assume responsibility for leadership, but how their time is allocated and to what degree groups or departments are willing to incentivize people will always be issues.
|Andrew W. Litt, MD
LITT: As a specialty, radiology is facing challenges similar to those seen in other fields of medicine. Physicians are questioning their lifestyle and quality-of-life choices. The rewards of leadership in a stressful, rapidly changing environment are tempered by the associated stress. In our field, these issues are even more extreme due to the shortage of radiologists nationwide and because of the complexity of the field, its demands for technical expertise, and the relatively little support that most radiologists receive from medicine in general.
|Patrick C. Malloy, MD
MALLOY: The dearth of leadership in radiology may, in part, be attributed to the absence of a well-defined career path for physician administrators. Although this may be true for other specialties in medicine, the demands on radiology leadership for knowledge of the business and administrative aspects of medicine are substantially more than in other fields. Regulatory, safety, compliance, and US Occupational Safety and Health Administration issues are magnified by the large volume of patients. In addition, the time constraints imposed on radiology chairs leave little time for academic development, thereby making the position less attractive to radiologists early in their careers.
|Lawrence R. Muroff, MD
MUROFF: At least at the national level, there is a strong group of leaders in the major imaging organizations and a robust pipeline of leaders in waiting. A potential problem is that new leaders are picked by the old, and conformity of thought is highly valued. There is little tolerance for the individual who says what needs to be said or thinks outside the box. Somehow, these voices need to be heard, and, when appropriate, rewarded. On the academic front, there are disincentives for practicing good business or providing aggressive leadership that stifle any innovative academic leadership initiatives. The radiology personnel shortage, inadequate compensation for department members, and turf concerns add to a chair’s burdens and discourage many good candidates from pursuing leadership positions. In private practice, there is often a pathologic addiction to democracy. This can result in either a rotation of leaders (including those who are totally unsuited to the position) or inadequate time allocated for leaders to fulfill their responsibilities.
Q:What is the best preparation for taking a leadership position in radiology and finding common ground with hospital administrators?
|Howard B. Kessler, MD
KESSLER: Experience, experience, experience: most leadership roles are unique. While formal training through graduate education leading to Master of Business Administration (MBA) and Master of Health Administration (MHA) degrees is desirable, most individuals come into their roles through experience, knowledge, and aptitude for decision making and planning. Formal training is an option. What may be a prerequisite is a sound understanding of contracts, marketing, accounting, and finance.
LITT: One can acquire leadership skills in a variety of ways, but one should definitely have some leadership experience on a small scale prior to becoming a chair. The most important knowledge that a leader needs is not finance or operations, but the ability to motivate, stimulate, and, sometimes, counsel colleagues. The content-oriented skills become more important when dealing with nonphysician administrators, but, even there, the ability to listen and understand their perspective is what will produce results.
MALLOY: Ideally, radiology chairs would obtain additional formal training in business or administration, such as an MBA or MHA degree. The reality of the demands on any chair in an active practice, however, often precludes devoting sufficient time toward formal certification. In the absence of the ability to obtain formal degrees, in-depth courses in health administration would be extremely useful. These should be applicable to all leadership in medicine.
MUROFF: Education does confer a major advantage by providing focus and adding skills to business experience. Insufficient recognition has been given to the value of mentoring. This on-the-job training by a skilled leader not only permits the trainee to learn specific business tasks, but usually gives him or her firsthand exposure to tact, compassion, and other personality traits that augment business acumen. One major leadership skill that is often overlooked in radiology is communication. I cannot emphasize strongly enough the need for all national leaders to get formal media training. This training will benefit anyone in, or seeking, a radiology leadership role.
Finding common ground with hospital administration can be a daunting challenge. It is in the best interest of all parties to realize that radiologists and their hospitals are inextricably bound, and what benefits one side will benefit the other. Factors such as contract terms, unreimbursed indigent care, turf, outside ventures, night and weekend call coverage, and the provision of subspecialty expertise can lead to intense polarization. Complicating these issues is the radiologist shortage, which has caused some radiology groups to question whether they even want to practice in a hospital setting.
|Martin L. Silbiger, MD
SILBIGER: Leadership requires business knowledge. An MBA is a minimal requirement.
Q:Should residency programs teach the nonclinical skills that practicing radiologists, as well as future leaders, will need?
LITT: Residents should learn skills in relationship building and service orientation. Radiologists, whether in academic practice or private practice, are highly dependent on their colleagues for clinical referrals and research projects. Residents should probably also be taught some basics of radiology practice finance, more to speak the language than to manage a department.
MALLOY: Residency programs should incorporate basic lectures in practice management as part of ongoing training in nonclinical skills. It seems, at this point, that the best faculty to teach residency skills would be practice administrators and faculty of associated business schools.
MUROFF: The best way that residencies can provide some of this leadership/business training is through exposure of residents (and staff) to nonclinical topics at grand rounds or morning/afternoon conferences. Topics such as ethics, communications, medicolegal considerations, and how to evaluate a job offer are all worthwhile for such conferences. While everyone should be exposed to these basic topics, only those with leadership aspirations should pursue more specific training. These subjects should not be a part of a residency, but, rather, might be provided by a national society, a specialized fellowship, or a business school.
SILBIGER: Only residents interested in management should spend any real time on this. Postresidency training is the best time.
|Jonathan W. Berlin, MD
BERLIN: The formal skills needed include familiarity with financial spreadsheets, financial decision making, organizational structure, and market analysis. These skills can be acquired while obtaining an MBA degree, but it is difficult to imagine these courses taught at the residency level.
KESSLER: The gain from an additional month of training in a modality or developing a skill is incremental. A month or rotation in contracts, finance, administration, operations, and developing negotiating skills is invaluable. The options would be either a mandatory rotation or an elective in these areas.
Q:What role should national societies assume in helping radiologists pursue leadership positions?
MALLOY: National societies could assume a role in outlining a career path for radiology leadership for junior faculty. Perhaps the societies could work toward the development of a certificate of added qualification in radiology health administration. National societies should recognize and promote those individuals who are actively involved in radiology leadership.
MUROFF: The national imaging societies have become quite active in the education and nurturing of future leaders. One group is promoting research funding for young investigators, providing assistance with grant writing, and presenting socioeconomic courses, and it has conducted a business-oriented course for future leaders. A second organization has held managed care workshops in the past, and a third is planning leadership courses.
SILBIGER: National societies have not demonstrated support for this. To move it forward, they must fund positions to help interested young radiologists as they fund research radiologists.
BERLIN: The societies could play a large role in encouraging residents and young physicians to consider a leadership position. The society-supported Introduction to Research program introduces residents to formal academics, including research projects, grant writing, and teaching. A similar program could emphasize the skills needed to lead people.
KESSLER: National societies are not configured to provide this benefit or value. Given the time it would take to reach consensus, it is not worth the effort.
LITT: The national societies have done a good job in recognizing a variety of leadership positions as valuable. They could do more to offer training opportunities for those beginning a path to leadership to be able to work with established leaders. Organized mentoring programs, similar to those used in research, should also be pursued.
Q:How should institutions select individuals to chair radiology departments?
MUROFF: Chairs of radiology departments are usually selected for the wrong reasons. This is particularly true in academia. The number of scientific articles that an individual has published rarely correlates with skills in finance, practice management, personnel deployment and development, communications, interdepartmental politics, and the myriad other tasks that face a modern chair.
SILBIGER: Business education and management experience are important in department chair selection. This is true in both private and university settings. The university culture, however, has a hard time accepting it.
BERLIN: I obtained formal training in management, but I also believe that familiarity with science and research is essential. An academic chair must know the value of research and must be well versed in the resources needed to sustain cutting-edge investigation, but this knowledge alone is not enough. A chair should participate in the day-to-day activities of the department, must be a good communicator, and must have the vision and flexibility required to anticipate the adjustments needed to adapt to the constantly changing health care environment. Search committees should pay more attention to communication skills, charisma, flexibility, and training in management, in addition to science and previous academic publications.
KESSLER: There are clearly individuals who desire an academic environment for a variety of reasons: ego, notoriety, or a desire to teach or administer. All too frequently, radiology chairs are chosen based on skill sets that are not applicable to running a large department. In many instances, department (and section) heads have been chosen based on a skill set focused on teaching and publication, and they have been abysmal failures. In many ways, the vacuum in academic leadership is reflective of this. I recognize that institutions of higher learning are charged with the mission of teaching, education, research, and clinical care; this is precisely the problem. These noble causes are pursued without the focus and attention to detail found in the world of business and finance.
LITT: Formal business education is not a substitute for other skills, but a broad range of experience is probably most valuable. Much will depend on the institution involved. Demonstrated leadership ability and experience are what count.
MALLOY: It is important to convey to the radiology chair the value of continuing business education and experience by formally recognizing those individuals who continue to advance their careers in this manner. The days of the triple threat are gone: it is impossible, in today’s health care climate, for any individual to be an outstanding clinician, researcher, and administrator. Academic institutions have traditionally based recognition and advancement on research, but institutions must find a mechanism for recognizing individuals with administrative and business experience.
Q:What is the best division of a radiology chair’s time?
SILBIGER: Time allocation (and pay) depends on the size and complexity of the job. Private groups often underestimate the challenge and expect the chair to be just as productive as the others in the group clinically. This is unrealistic and leads to lousy management or poor clinical performance.
LITT: In large departments, more time will need to be spent on administrative functions; however, the chair should never give up nonadministrative responsibility completely. Whether his or her time is spent reading cases, teaching, or doing research, it is important for a leader to lead by example.
MALLOY: It is essential to maintain an active clinical role in order to manage the department and to stay as current as possible with new technology and techniques. The optimum division of time is 40% clinical and 60% administrative. In the academic setting, with proper support, one may be able to maintain a schedule of 30% clinical, 20% teaching and research, and 50% administra-tive time.
MUROFF: In a small private practice, the chair may spend little time on group affairs (assuming the presence of a competent radiology business manager). In larger private practices, the time allocation for a chair can go from full-time clinical practice with administrative chores performed after hours to full-time administrative duties with no clinical responsibilities. In the latter situation, there are often problems with other group members, who invariably undervalue administrative tasks and underestimate the time needed by the chair to function on behalf of the group.
In academia, chairs have teaching and administrative obligations, must often serve on committees that have no relationship to their departments, and have far more nonclinical time commitments than their private-practice counterparts. Academic chairs often try to spend time on clinical rotations and/or research when that time might be better spent on administrative chores. It might be better to let researchers do research and select chairs for their business acumen and management/political skills.
Q:What advice would you offer potential radiology leaders?
KESSLER: Treat the practice of medicine like the business of medicine. Frequently, academicians fail to comprehend the link between sound business practices and a successful radiology department. They live in a world focusing on the mission, but they need to understand a simple phrase: no money, no mission. Physicians need to abandon the notion that the business of medicine is a dirty little secret. There are innumerable lessons of business parasitizing the world of medical imaging. Intransigence leads to opportunities for others. Few would argue against the idea that radiology needs to develop a business mentality if it hopes to preserve both the breadth and level of excellence to which we are accustomed.
LITT: Learn about the world outside of radiology and how what we do affects the rest of medicine.
MALLOY: Pay particular attention to time-management skills and to the development of an effective radiology management team. The team must contain individuals with diverse backgrounds (technical, business, regulatory, and information management). A strong radiology management team will provide the chair with appropriate support to manage tasks and avoid excessive personal demands.
MUROFF: Take everything seriously, except yourself. Think clearly before acting decisively. It is virtually impossible to change the culture of a group or organization radically; work within the system. Respect the history of the group or organization. Benefit from media training. Remember that, ultimately, there is no substitute for hard work.
SILBIGER: Get formal business training. We grossly underestimate its importance.
Q:Should being the chair of a radiology department be seen as a career episode or a goal?
LITT: Being a radiology chair is definitely a legitimate and worthwhile career objective. That does not mean that it is without challenges and difficulties. It is not a goal for every individual; the goal would be enhanced if there were greater institutional and national support for the role.
MALLOY: It is difficult to make the transition to effective leadership, often requiring several years to assume the responsibilities of the role completely. It is, therefore, advantageous to the department to have an effective chair in place for a long period, rather than using the rotating-chair model.
SILBIGER: It depends on the individual. The reward is seeing a well-thought-out plan succeed. It can become a goal if one enjoys working with a group and seeing it thrive. One must enjoy the success of the group as a whole.
BERLIN: Becoming a radiology chair is a legitimate career path and a worthwhile goal. Being a chair offers a different type of satisfaction than that achieved if one is solely in clinical medicine. Essentially, this satisfaction comes from ownership. A chair has the opportunity to steer a department through murky waters and is left with the sense of accomplishment that comes from selecting a successful course. In addition, a chair has the opportunity to put his or her own unique stamp on a particular institution, which is quite satisfying.
Kris Kyes is technical editor of Decisions in Axis Imaging News.