Robert L. Bree, MD

There is no bigger dilemma facing radiology than the shortage of radiologists and radiology technologists, and it is a problem that may get worse before it gets better.

According to American College of radiology statistics,1 no matter the scenario for the futurewhich could include everything from doing nothing to lowering the length of residencies to eliminating fellowshipsthe radiologist growth rate will stall at about 2% through 2030 while demand, overall, for radiologists will continue to grow 2% to 5% per annum.

The demand for radiology technologists is more pressing, with the Bureau of Labor Statistics (BLS) projecting that the country will need 75,000 more technologists by 2010 than it had in 2000. Based on the BLS figures, the American Society of Radiologic Technologists (ASRT) estimates that there will not be enough radiology technologists to meet this demand. Current projections peg the number of working radiographers in 2010 at 52,325, about 30% lower than the projected need. The ASRT figures assume that the number of students entering training programs, the student attrition rate, the examination pass rate, and the discipline’s retention profile will remain stable until 2010.

Steve Mattson, RTR

That staffing shortages are projected to continue does not mean there are not solutions. Hospital radiology departments, imaging centers, and radiology groups throughout the United States have resorted to increasingly innovative methods to fill empty FTE slots, and could provide a model for solving individual staffing needs.

Physician Extenders

To offset its radiologist shortage, the 45-person Radia Medical Imaging, Everett, Wash, trained two experienced physician assistants certified (PA-C)who had been radiology technologiststo administer several radiologic procedures including fluoroscopy, lumbar punctures, tube placements, and joint injections. This solution was born out of necessity. Radia had attempted to hire graduates of the Weber State College radiology physician assistant (RPA) program, but found that the state of Washington would not honor that program’s credential. “We had no other choice,” says Robert L. Bree, MD, a Radia radiologist and medical director for imaging at the 362-bed Providence Everett Medical Center. “The state said we couldn’t use rad techs and we couldn’t use RPAs, so there wasn’t another choice.” PA-Cs are certified by the American Academy of Physician Assistants (AAPA), Alexandria, Va, and licensed by each state, as are physicians.

James P. Borgstede, MD

The group trained both of the physician assistants who were hired in the fall of 2002. They were put through a 3-month training program in the practice. Final competency was determined by the Radia person in charge of training.

Radia Medical Imaging is a full-service group that covers five hospitals in the Seattle area. In 2002, the group did 700,000 studies, and is seeing a growth rate of 15% to 20% per annum. Currently, Radia is short eight radiologists. One PA-C is being used to eliminate a half FTE. Bree says that the number of FTEs the PA-Cs will fill may vary from site to site.

Because the two physician assistants have just assumed their duties, the long-term financial benefits have yet to be determined, though they have already allowed the group to realize cost savings: two physician assistants cost less than a single radiologist. “If we can save a radiologist FTE and replace it with two PA FTEs, that’s significant savings,” says Bree. “The differential is quite significant.” The physician assistants work under the supervision of a radiologist and do no interpretation.

Monte G. Clinton, CRA

Bree sees the use of physician assistants as a long-term solution since he says there will always be a radiologist shortage. The group expects to use a physician assistant school in the state of Washington as a feeder system from which it will get more personnel, and has begun taking some of its students as part of their clinical rotation.

Feeding the Solution

As these feeder systems become increasingly strained, some institutions are becoming quite proactive in helping to build new feeder systems.

Currently short six technologists, and with the need to staff four recently approved MR technologist positions, the radiology department at the 400-bed Dartmouth-Hitchcock Medical Center, Lebanon, NH, has developed a three-tier approach that is filling immediate staffing shortages and promises to provide a long-term solution.

In the midst of adding 25,000 square feet to its 50,000-sq-ft radiology space, the department will eventually require 20 new technologists to supplement its team of 70 to staff this addition 24 hours a day, 7 days a week. The department does about 210,000 imaging studies in all modalities per year. Monte G. Clinton, CRA, administrative director of radiology, says that because it is difficult to induce people from other areas of the country to move to New Hampshire, the hospital had to look closer to home for potential employees.

The long-term solution involved Dartmouth-Hitchcock in helping a local community college set up an x-ray technologist program. “It’s the college’s program, but we helped them in equipping their facility,” he says. “It’s probably one of the best-equipped x-ray schools anywhere, because we had a considerable amount of equipment we were replacing when we were taking out conventional x-ray rooms and putting in digital x-ray rooms. They have a very nice live lab and another practice lab.”

The first class of 15 students will be joined by a new class of 18 in the fallall are local residents. The first class will graduate about the time the radiology addition opens. About seven of the students in the first class were already hospital employeesincluding four from the hospital’s soon-to-be defunct film library. To entice employees to take part in the program, the hospital will help students secure a bank loan to pay the program’s tuition, paying the interest on the loan while the employee is in school. The bank loan will be forgiven if the new technologist works at Dartmouth-Hitchcock for 3 years. The employee-students will be allowed to work part-time, but still receive full-time benefits. Dartmouth-Hitchcock is not the only hospital that could benefit from the new training program; there are seven area hospitals vying for these students.

In the meantime, there are several stopgap measures that the department has implemented to leverage its technologist staff. These include the use of technologist aides or extenders to make the technologists more efficient. These extenders’ duties include transporting patients and bringing films to the radiologists.

Because New Hampshire does not require licensing for technologists, the department recently also has begun to use senior technologist students to cover the department during lunch time from 11:30 AM to 1:30 PM, allowing the department to run at full capacity. The students are paid while covering the lunch period.

The department also recently has gone filmless, with the addition of six digital radiography rooms, which Clinton says the hospital hopes will make the technologists 30% to 40% more productive.

Ladder to Success

But having technologists on board is only part of the solution. Keeping them is another matter entirely. One way to do this is by building a career ladder.

Short five CT technologists, Denver’s Kaiser Permanente found the technologist shortage most acute in CT. Kaiser has about 200 employees in radiology service throughout its 17-site Colorado regional system, and in 2002 performed more than 300,000 procedures across all modalities, a number that is increasing at a rate of about 7% per year. To meet this need for more CT technologists, the outpatient radiology department looked to an untapped labor force under its very nose in the form of its radiology technologists, many of whom wanted to move up in the profession. “There was no place for upper mobility, so what we established was an educational committee,” says Steve Mattson, RTR, radiology supervisor, Kaiser Permanente 20th Avenue Medical Center. “[We got together] to figure out how to establish a cross-training program. Out of that initial meeting 2 years ago, we identified what that program would look like.”

The 480-hour, 3-month cross-training program took 6 months to set up and included the appointment of a program director, and the training of preceptors who would administer the program. Interested employees had to go through an interview process. The first three students from a field of seven were chosen mostly on merit. “Even though we are in a union environment, we didn’t want to make this strictly a seniority-based program, so the people who are selected aren’t necessarily the most senior radiology techs in the regionthey have to get in on merit,” Mattson says, adding that both the health system administration and chief radiologist were very supportive of the program.

The first student went through the course in July 2002. The participants were paid throughout training. When they completed the course, they received an upgrade in pay and had to agree to work 6 months on the night shift. After their 6-month stint on the night shift, the new CT technologists would be eligible to bid on jobs on other shifts, as openings occurred.

Though the program works well, Mattson admits it still has not solved all the department’s problems: It had to hire more experienced technicians from the outside to shore up the night shift, which has had some attrition because of experienced personnel moving to other, more desirable shifts.

The pluses of the program, particularly for the employees, outweigh any of the drawbacks of the evolving career ladder, and has opened the way for continued upward mobility for the CT technologists. Once the technologists prove they are competent, then they are eligible to move up on the next rung of the career ladder to MRI technologist. The first person who went through the CT cross-training program is currently being trained in MRI.

Mattson says that the program has already been successful enough that Kaiser Permanente is considering implementing it at a national level.

Developing programs to solve individual radiology technologist shortages is only half the battle. Radiology groups also are taking innovative steps to get the best and the brightest radiologists.

Snaring Fellows

Twice between 1998 and 1999, Colorado Springs Radiologists, PC, found themselves in a dilemma. Two Air Force-trained radiologists, with whom they had worked, were leaving the military and were interested in joining the group. The problem was that neither was fellowship-trained, a requirement for joining the group. Both men were reluctant to return to school and live on a fellowship stipend.

So in a brainstorming session, the partners came up with a unique solutionthey would supplement the stipend, if the military radiologists agreed to do a fellowship in one of the areas the group needed and if they agreed to work for the group for a year after they completed their fellowships. The supplement came from the fellow’s first-year salary in an amount determined by the radiologist, not the group. Though this made both men’s first year with the group after the fellowship a little rough financially, says James P. Borgstede, MD, FACR, vice president of Colorado Springs Radiologists and a vice chairman of the Board of Chancellors for the American College of Radiology, it sold both men on doing the fellowship and turned into a positive for everyone involved. “This wasn’t any great altruism,” he says. “It was a win-win. It enticed them to do the fellowship. We got quality, fellowship-trained people. And the university got fellows for a year.”

The fellowshipsone in pediatric radiology and one in chestwere completed between 1998 and 2000. Both radiologists are still part of the group, which at the time numbered 12 and was short two radiologists.

Since 2000, three more fellowship-trained radiologists have joined the group. In 2002, it did 259,000 examinations, and volume is growing at about 12.25% annually.

Borgstede says that the program will remain informal, used only if an experienced, non-fellowship-trained radiologist is either the only or best candidate for an open position. “The arrangement that we made with these people worked out well,” he concludes. “It was somewhat informal, and we would do it the same way again, I think.”

In all preceding solutions to the problems of staffing, there is one recurring theme that has marked success for the hospitals from New Hampshire to Denver to Seattleinnovation. As Borgstede observes about his own group’s solution, “The group came up with this solution, we didn’t get it from a book.”

Chris Wolski is associate editor of Decisions in Axis Imaging News.


  1. Bhargavan M, Sunshine JH, Schepps B. Too few radiologists? AJR. 2002;178:1075-1082.