Where Have All of the Radiologists Gone?

Everyone remembers the fable of the genie in the bottle and the receiving of three wishes. These days, administrators in both academia and private practice would no doubt have the same three wishes: radiologists, radiologists, and more radiologists.

The shortage crossed administrators’ radar screens about 2 years ago and, according to some prognostications, may last for the foreseeable future. “It became obvious to anybody who was trying to recruit,” comments David Levin, MD, PhD, chairman of the Department of Radiology, Thomas Jefferson University, Philadelphia, “and this was a very marked turnaround from about 3 years ago, when there was an abundance of radiologists.” He adds that the shortage “is pretty much across the board: for people who are generalists, and those who are subspecialists.” There is unanimous agreement with Levin’s comments from those experts that Decisions in Axis Imaging News talked to about this subject, with others highlighting acute shortages for radiologists with expertise in interventional, angiography, musculoskeletal, women’s imaging, pediatric, emergency/trauma, and MRI.

The radiologist shortage is not only tangible in hospitals and private practices nationwide in the United States, but the effects can be seen also in health care facilities in the Canadian provinces from the Maritimes to the Northwest Territories. The impact is being felt not only in rural regions (where traditionally groups have had more of a challenge in luring radiologists away from the big city), but now in the high-density metropolitan areas as well. According to Mitchell Shenker, a recruiter at Hitchens & Foster, a division of LarsonAllen Search LLC, St Louis, who specializes in placing radiologists and radiation oncologists, “As a recruiter, you don’t normally make your living [solely] getting job orders in major metropolitan areas, but in this year alone, I have had more job orders there than I can ever remember.”

In an effort to gain insight into the present shortage, its causes and effects — as well as tips on how to recruit and retain these elusive personnel — Axis Imaging News interviewed department chairs at teaching hospitals, radiologists in groups at several different US locales, recruiting agencies, and human resource specialists. The consensus is that the problem did not appear overnight and may continue for the next 3 to 5 years.

The Managed Care Conundrum

The present shortage of available personnel has many progenitors. Experts point to an interlinked, yet cascading effect of funding reductions in both residency programs and capitalization for new equipment, overworked radiologists opting for early retirement, and increasing demand for services from the growing population of elderly Americans, as well as the splintering of subspecialty opportunities for radiologists (for example, where one would historically have had a need only for a neuroradiologist, now there are diagnostic neuroradiologists as well as neuro-interventionalists). But the consensus is that all these factors are overshadowed by the bugbear of managed health care, which many believe is the source of the present problem.

“What I think happened, and other chairmen have the same feeling, is that 3 or 4 years ago, managed care concentrations increased to the point where many practices believed that they had to hold off adding more radiologists,” comments John Breckenridge, MD, head of the radiology group of Abington Memorial Hospital, Abington, Pa, and president of the Pennsylvania Radiology Society. “The initial event of the increase in managed care caused a feeling on the part of radiology groups that they were going to lose income. The response to this perception was to work harder to maintain their income level.”

Howard Forman, MD, a health economist and radiologist at Yale University School of Medicine, New Haven, Conn, agrees, adding that the hiring freeze was “predominantly due to dramatically reduced fee reimbursements caused by the increase in managed care, as well as by Medicare conversion factor decreases.” Subsequently, radiology groups became more efficient through the use of their equipment and available personnel, and the end result was that groups’ incomes stabilized.

But that meant that radiologists were not being hired. Dan Haber, a recruiter with JNC Nationwide, Atlanta, notes that when he first came to work at his present firm about 4 years ago, there were too many radiologists. “No one would pay a recruitment fee for them.”

Shenker agrees, adding: “Three to 5 years ago, the present situation was 180 degrees from where it is today. Radiologists were begging for jobs, and they would take anything just so they could go to work.”

The recruiters’ comments are echoed by statements in an article that appeared this past April in the American Journal of Roentgenology (AJR): “The advent of managed care in the 1990s, and the media-dispersed stories of jobless anesthesiologists, likely provoked a national scare among radiologists, with a resulting generalized freeze on new hires….Literature consistently suggests that managed care has a negative effect on hiring.”[1]

With a plethora of radiology personnel looking for jobs in the mid-1990s, it seems that the effect was multi-pronged:

• Nationwide, teaching hospitals closed down radiologist residency and fellowship slots, as monies for expanding programs dried up;
• Many employed radiologists believed that they were being overworked in the new managed care environment, and decided to retire early;
• Radiologists who could not immediately find work in their chosen field instead went into information technology-related jobs, became freelance consultants, or — if they were still in training—extended their fellowships; and
• There was a growing perception that many medical students decided not to pursue a career in radiology.

As Breckenridge wryly notes, “The word got out that radiology was a bad place to be.”

In the Trenches

The perceptions and stories of those interviewed for this article highlight in dramatic fashion the fierceness of the current competition in acquiring that just-right radiologist, and provide insights to what is happening right now in the trenches. As Haber points out, “[There are] needs all across America. I don’t think there is any one particular area where they have enough radiologists and they have no problems recruiting.”

Haber continues: “Just to give you a case in point — Florida, a very desirable state. I have a large need there right now for radiologists in all subspecialties as well as generalists. Usually it doesn’t take twisting someone’s arm to go to Florida. But when you have Florida-based clients calling in here on a daily basis, then you know there is a shortage.”

Recruiters are finding that practices that come to them for help in locating radiologists are willing to pay an average fee of $20,000 to $25,000. “Organizations such as ours are coming even more into play as physicians are looking for any possible way to fill [their] need,” according to Shenker.

One radiology department head in eastern Pennsylvania comments that he was looking to hire four new radiologists, and then learned to his dismay that several other local facilities were also looking for an equal number. One New England-based group decided to preempt its competition, and hired a radiologist still in residency training to begin work in July 2001. Indeed, one recruiter in the Southeast has a musculoskeletal radiologist who is one and a half years out from completing his fellowship, and already has 11 employment interviews scheduled with interested physician groups. “If you were an interventional radiologist, you would be just like a sports free agent,” Shenker says. “If any fellowship-trained interventionalist says, ‘I’m on the market,’ he will have between six to a dozen opportunities to look at — and he may get offers from all of them.”

REFERENCES

1. Forman HP, Kamin DS, Covey AM, Sunshine JH. Changes in the market for diagnostic radiologists as measured through a help wanted index. AJR Am J Roentgenol. 2000;174:933-938.

For new graduates, the present hiring environment is quite unlike any previous. Robin Levy, a health care consultant specializing in diagnostic imaging and president of the Compass Healthcare Group, Owings Mills, Md, points out that, unlike in the past, many new hires are finding that their careers have been accelerated: “I think that the new graduates who are coming out recognize that there is a shortage. Certain clients of mine would not prefer people coming out directly from fellowships, simply because they lack a level of seasoning and experience. Now, those individuals are likely to be hired and given opportunities that, historically, they would not have had as early in their career. They also are being offered higher starting salaries as they are being competed for nationally. Additionally, the package benefits are getting enriched, such as taking care of relocation and insurance expenses, and shorter partnership tracks.”

Statistics Highlight Decline

The problem is pronounced enough to have generated considerable inquiry in the literature.

In a paper that appeared in AJR, researchers at the American College of Radiology (ACR), Reston, Va, stated, “The most important question we sought to answer was whether the number of positions available?was enough — or too few or too many — for all the radiologists needing [jobs].” The approximate figure the researchers established for 1997 was 1,909 positions, with 1,631 radiologists needing employment. That meant 278 openings went begging. [2]

According to information provided by Jonathan Sunshine, PhD, director of research at ACR, the trends for 1998 (the most recent information available) indicate that hiring increased. But the number of unfilled job slots was “about the same” in magnitude as the situation in 1997. Furthermore, on the basis of other information he and his colleagues are tracking, Sunshine believes that the number of unfilled positions was larger in 1999 than in 1998, and that there are indicators that the number of openings that will go begging this year will be following the same trend—increasing.

In Canada, the information available depicts a graver situation. Last November, in the Canadian Medical Association Journal, Sibbald reported that of the estimated 2,500 positions in Canada, 105 radiologist slots are vacant.3 According to Normand Laberge, MD, CEO of the Canadian Association of Radiologists (CAR), the situation is much more serious. In addition to the openings, 12% of Canadian radiologists are at retirement age, and another 10% are considering retirement. These potential numbers indicate the shortage north of the border could reach as high as 26% in the near future.

Furthermore, there appears to be a crisis in having enough doctors in the training pipeline. Sibbald’s article reported that surveys conducted for the CAR in 1994/1995 and in 1997/1998 indicate that the number of unfilled positions in Canada rose from 59 in 1995 to 105 in 1998, while the number of new radiologists being produced declined from 87 in 1994 to 69 in 1998. [3]

Looking at US figures supplied by Sunshine, the data for diagnostic radiology trainees graduating and becoming available for employment show approximately constant numbers — with some fluctuation — hovering around 1,000 for the past 5 years, including this year. In 1996, there were 1,000 students available for hiring. In 1997, the figure fell to 980, which then rose to 1,060 in 1998, but in the following 2 years the numbers tapered off again to about 1,040 graduates. It should be noted that Sunshine’s figures are at odds with the general perception that slots have been reduced, and that students have refrained from choosing radiology as a career. His figures are from an annual survey of training program directors, who report how many students graduate from their programs each year.

Despite the apparent steady stream of US graduates, a major factor in the present shortage is the fact that radiologists are retiring, and they are retiring earlier. Levy comments that “radiologists who might have been anxious to retire have been asked to stay on, because we [the radiology community] are so desperate in the job market.” According to figures reported in the ACR’s previously mentioned paper on radiologist hiring in 1997, “a new, large wave of retirements appears to have begun about 1996, and in 1997, retirements were approximately double [816] the usual number. We suspect that financial and administrative developments in medical practice in the past few years are producing discontent that has led to an increase in retirements.” [2] According to Sunshine, the 1998 figures for American radiologists leaving the profession “remain elevated.”

Untying the Gordian Knot

As administrators scramble to fill their open job slots, they should keep in mind that tens of thousands of their colleagues are doing the same thing. “What we are seeing right now is a genuine shortage nationally across every single specialty there is,” Forman says, and “radiologists nationally are reporting an easy time finding ideal positions.”

But what does ideal mean? For many radiologists, especially those in academia, it may mean opportunities to conduct dedicated research, to teach, to stay involved in everyday radiology, and to be guaranteed long-term employment. For others who wish to go into private practice, it may mean high signing bonuses, willingness to work hard and maximize their annual income, earlier partnership tracking, shorter work weeks, and, most especially, high starting salaries. Still others may have more personal needs — they may wish to move near an ill loved one, obtain loan-forgiveness packages or help in finding housing, have easy access to cultural activities, get 15-week vacations, leave behind personality clashes where they are presently working, or just move to where their spouse had recently acquired employment. Forman comments that “I think there is more of a trend to hire people and give some type of better arrangement from the usual—which is more typical of the private sector than the academic sector. But that’s starting to happen more and more everywhere. Overall, salary on the low end has crept up.”

When asked what the impact the shortages had on salaries that were being offered, the consensus was that these were precipitously increasing. “Extremely escalated,” Shenker emphatically responded. “Three years ago, for instance, a radiology resident — in other words, one not fellowship trained — probably would be offered $125,000 and $150,000 at the top side. Now that offer today in metropolitan areas is $200,000 on average. Also, in smaller communities, I have jobs on the board I can’t fill where they will be willing to pay $250,000 to $300,000 to just get a radiology resident to come and live in their community. You see astronomical increases percentage-wise — just like you see in baseball.”

Treat Them Right

Besides increasing salaries, other considerations administrators need to look at include the environment in which the radiologists work. Levy believes the approach should be on a personal, one-on-one basis: “Aside from the monetary issue, professional gratification or lack thereof, as well as efficiency in group or departmental leadership (in responding to problems and requests from the radiologists), is a critical, important reason why people leave. You can include poor communication, lack of follow-through, as well as the lack of appreciation and/or acknowledgements as things that can be added to that list. Administrators must enhance communication, evaluate compensation and benefit packages comparable to what is happening nationwide, and provide ladders for professional enhancement and management advancement.”

Others add that having the most current diagnostic equipment available, workloads that are not excessive, and an environment in which the radiologist is valued for more than a year’s worth of billings are further factors worthy of attention by administrators and department heads. “Each individual radiologist has to be looked at as an investment in a future career with that organization,” Forman stresses.

Additionally, Levy warns, “Younger people coming into the market today are not looking at job opportunities necessarily with the same longevity prospects as applicants did 10 years ago. They have no hesitation about working at a firm for a short amount of time, say 2 years, and then moving on. We live in a world where changing jobs for them is not a frightening prospect. These fellows and residents coming out of training, these same young colleagues in different fields, look at the job market as a tremendous opportunity for mobility.” Shenker amplifies Levy’s comments by adding that 60% of the radiologists who take their first job change positions within the first 5 years.

In this new hiring environment, the standard strategies that have traditionally been used to attract newly minted as well as veteran radiologists have to be expanded. The use of relatively new methods is taking center stage.

The newer procedures are taking the form of: Heavy usage of the Internet (such as the ACR professional bureau online) and postings on subspecialty boards (like the Society of Pediatric Radiology); ever-earlier direct contacts with radiologists-in-training during their residencies and fellowships; and the very extensive use of recruiters who specialize in the field. All of these are augmenting — and in many cases, replacing — the previous standard submissions of advertising in the regular print media. As Breckenridge observes, “If one tries to run an advertisement in the major radiology journals, or state journals, the wait for it to appear from the time of submission can be as long as 3 months.”

Additionally, Forman notes, “I think a strong network of word-of-mouth, group communications, and networking [remain good ways] for recruiting. But I do think there is a big role still for generic traditional advertising, as well as for newer modes such as the Internet and national meetings where postings and discussion groups form.”

The hunt for radiologists is overwhelmingly pervading all avenues of recruiting. From an advertising copy salesperson’s view, the traditional help wanted sections are a dream come true. And researchers who have been following these trends have quantified this. In the paper by Forman et al, the authors looked at all jobs advertised in Radiology and the AJR (13,701 postings) from January 1991 through December 1998. The researchers found a dramatic decrease in job advertisements after December 1991, with the number falling to its nadir in mid–1995, continuing through mid–1996. However, since then, the numbers have continued to increase substantially every year.1 Sunshine comments that the number of jobs advertised for radiologists in 1999 was higher than in 1998, and this year it is likely to be higher than in 1999.

Because of the shortages, radiologists nearing retirement are being asked to delay exiting their careers.”If people are coming upon retirement, they are being asked to stay on full-time or even part-time a little longer,” according to Levy. “Some are being asked to consider taking enhancing educational/academic courses solely to allow for other people to focus more on the clinical side. In this present environment, a more creative approach to aging radiologists who still retain skill levels and can work in the support of high-quality care is very necessary.”

Coping with the Crisis To Come

As the shortage of radiologists continues, the pressure to provide and maintain timely services at facilities around the country will increase. Creative measures are going to become more and more necessary to handle the growing amount of radiology work. The job shortage market is forcing people to support each other, rather than compete as it historically has been. This has left academic institutions looking in the same city for other academic institutional support where shortages exist. Levy notes that there has also been an increase in moonlighting by those employed in both academic institutions and private practice because of the personnel shortfalls. “Practices need to be aware that their own full-time staff may become too tired or be worn too thin by working additional time in other practices that are experiencing shortages,” Levy warns.

One of the foremost issues as practices and departments work their way through the present shortages is how they approach and respond to critical issues. Programs and practices need to survive the financial burden that the present human resource quandary has placed them in. As Levy sagely observes, “If every doctor is making a million-and-a-half dollars, you’re in trouble. If you’re looking for comparable salaries, if you’re one-upping each other in the market, you have to make sure that in the end your business unit can sustain the deals that are negotiated.”

It is true that the present radiologist shortage will remain with us for some time to come. And as the aging Baby Boomer population grows, the demand for radiologists will increase along with it. And more and more creativity on the part of administrators and department heads will be required as they attempt to make best use of their staffing.

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Peter Pesavento is associate editor of Decisions in Axis Imaging News.