Help Wanted – NOW!

The radiologist shortage continues, and it is not going to get better in the foreseeable future. Professor Vijay Rao, MD, FACR, of Jefferson Medical College and other industry experts discuss the causes of the shortage and what can be done to fill in the gaps and, with time, fill those empty slots.

“There’s a lot of very new and interesting areas that they can practice. So I think interventional has a very bright future, but it’s going to take us some time to convince young trainees.” — Professor Vijay Rao, MD, FACR, of Jefferson Medical College

Radiologists Wanted. Apply Here. Please!

Looking for a radiologist? Interventionalist? Someone specializing in mammography, perhaps? Unfortunately, you are not alone. Hospitals, group practices, and outpatient centers are searching to fill empty radiology slots to meet the demands of aging Baby Boomers and health care’s thirst for digital diagnostic imaging. Experts say there is little hope that present or future imaging needs will be met without government support to increase the number of radiology slots at medical schools.

In the interim, facilities use dayhawk and nighthawk services as a quick fix, but these services can be costly and inconsistent—plus, they do not address the deficit of interventionalists. Increasing efficiency through technology and the use of physician assistants may be helpful, but these solutions also can be expensive. Nevertheless, unless administrators want to completely surrender their radiology departments to off-site services and the revolving door of locum tenens, it is perhaps better to make these investments sooner rather than later.

How It All Started

Health care is famous for staffing shortages. If a hospital is looking for a single radiologist right now, it is almost certainly looking for 10 nurses as well. Schools have recently kept up with the demand for radiology technologists, but experts warn that this trend is cyclical. On the other hand, the scarcity of radiologists today will most likely last for the foreseeable future, and there are several reasons why.

The current radiology shortage is not really that current at all, but has been growing steadily since the expansion of health maintenance organizations (HMOs) and the Balanced Budget Act (BBA) of 1997. The BBA affected the payments that Medicare gives to hospital residency training programs for direct and indirect training costs. These cuts forced teaching hospitals to make tough decisions about keeping the same allocation of slots in each discipline. At the same time, the growth of HMOs created a huge demand for primary care specialties, tempting residents away from radiology.

As both a professor and a hospital administrator, Vijay Rao, MD, FACR, professor and chair of the Department of Radiology at Jefferson Medical College and Thomas Jefferson University Hospital in Philadelphia, has experienced the effects of the BBA and HMO growth from two perspectives. Currently, she feels fortunate that Jefferson is short only one interventionalist. Some hospitals gave up radiology slots in favor of more primary care slots to meet HMO demands. However, since the 1990s, HMOs have become unpopular and their numbers significantly reduced.

For the past several years, the demand for radiologists has exploded thanks to new digital imaging technologies, outpatient imaging centers, new interventional procedures, oncology radiology, plus an increasing population that is living longer.

Despite imaging’s growth, few hospitals have increased radiology slots or even restored downsized programs from the ‘90s. “There are about 188 training programs, and around a thousand residents graduate per year. So, when you look at the increasing workload due to the growth in imaging utilization, the demand for radiologists outstrips the supply. Unless we increase the number of residency slots nationally and train more radiologists, this gap is only going to get wider and wider,” Rao said.

Paging an Interventionalist

Rao does not believe that the government will increase the number of allotted residency slots due to continuing federal budget woes, and she is not optimistic that institutions will restore downsized radiology programs due to institutional politics. Consequently, with the pool of new radiologists being stagnant, it is not surprising that radiology subspecialties are in even shorter supply than general diagnostic radiologists.

Mark Weiss, MD, an interventional radiologist and partner in Radiology Business Solutions (RBS), Flint, Mich, a radiology consulting company, said that the lack of interventionalists, breast imaging specialists, and neuroradiologists is so extreme that some practices have completely abandoned looking.

“Every group that we know of is looking for a physician. Now, are they actively recruiting? No. And the reason is that because, for a year or two, they spent a lot of resources on it, a lot of time interviewing, and they were unsuccessful. They’ve basically given up,” Weiss said.

Rao believes that the dearth of new residents choosing interventional radiology is partly due to perceived turf issues. She said that because residents perceive a cherry-picking of procedures by vascular surgeons and cardiologists for peripheral intervention, they are apprehensive about pursuing a career in interventional radiology.

As result, even premier fellowship programs such as Jefferson’s have suffered, leaving fellowship slots empty. Rao said that Jefferson has turned around its situation with a new “direct pathway” program, which folds the residency and fellowship under one umbrella. At the end of 6 years, students are able to take their board exam in diagnostic and interventionalradiology, as well as receive a valid fellowship from Jefferson.

Rao also sees interventional radiology having an increased interest because of the development of new cancer therapies, such as immunoembolizations and uterine fibroid embolizations. She said, “There’s a lot of very new and interesting areas that they can practice. So I think interventional has a very bright future, but it’s going to take us some time to convince young trainees.”

Daniel Corbett, chief of business development with Weiss at RBS, also believes that the large population of older radiologists who are downsizing their practices or retiring altogether exacerbates the overall shortage.

“There are no young radiologists lined up to take up the slack in the groups, so these doctors who are in the twilights of their careers and expected to slow down are working even harder,” Corbett said. “Politics are getting harder, and so a lot of them are getting out and getting into the locum industry.”

The Obvious Solutions

The obvious solution to the radiology shortage is, of course, outsourcing through locum tenens, dayhawk, and nighthawk services.

With the Internet and a modern PACS, it is possible—though expensive—for hospitals and outpatient centers to be covered by a diagnostic radiologist across town or across the world.

“I’m not pleased with that trend one bit,” Rao said of off-site services. “But I do understand the challenges that non-teaching hospitals have. Traditionally in teaching hospitals, residents provide preliminary reads after hours. But even in teaching hospitals, there’s a lot of pressure to provide 24 hours a day, 7 days a week, 365 days a year attending coverage, which is very challenging because academic radiologists are highly subspecialized. It’s just not doable with the number of people you have on your attending staff.”

That being said, Rao has a wait-and-see approach to nighthawk and its place in radiology. Her main concern about off-site services is that they have the potential to make radiology a commodity, where all radiology services are of equal quality, regardless of training or experience.

The same concern may be said of locum tenens physicians. Locums travel from job to job for a set period of time and are generally paid a premium per diem rate plus expenses. In addition, they have no obligation or incentive to stay beyond the contracted period of work, which can be as little as a day or several months. As a result, their quality and dedication can vary greatly.

“One doctor’s hard work can be different from another’s, so there are big differences in productivity from one locum’s radiologists to another locum’s radiologists,” Corbett said. “In addition to quality, their skill sets may be different. Some locum doctors don’t do MRI. Some don’t do mammography.”

Locums were traditionally used to fill in for radiologists taking vacations. However, because the radiologist shortage is so acute, Corbett said that he is aware of some hospitals where the entire staff consists of locum radiologists.

The other side of the coin for contracting with locum tenens is the possibility that they might actually stay. Having a locum for a few days or a week allows the institution and the physician to get to know each other. Of course, it may require a lot of synergy—and a competitive package—to convince a regional locum to stay in one place, risking evening calls and losing weekends.

The Less-Obvious Solutions

Even with a competitive salary, aggressive recruitment of a radiologist is only robbing Peter to pay Paul. Some hospital or practice is always going to have the short stick. An outpatient facility could at least choose to reduce hours or services, but then revenue would also decrease. Given the payment reductions mandated by the 2005 Deficit Reduction Act, a decrease in volume could put an imaging center out of business.

The more realistic solution is to make do with less. Essentially, that means dramatically increasing efficiency through better technology and software, such as a PACS with integrated voice recognition software, customizable hanging protocols, and all the whistles and bells that make imaging procedures paperless, filmless, fast, and lean.

In addition, if you have always wanted that brand-new 64-slice CT or 1.5 MRI with superfast throughput, leasing or buying it now may not only help the current staff, it may also attract more referrals from physicians and those Internet-educated patients who want services only from the facilities with the latest and greatest equipment.

Granted, improving efficiency through technology will be expensive, but it is perhaps more difficult to attract and retain a radiologist than to buy a PACS or CT. Plus, converting or upgrading to a new PACS will make nighthawk and dayhawk services that much easier and efficient.

For large radiology groups covering multiple facilities, another technology solution may be building a dedicated teleradiology center. Lynn Elliott, CEO of Radiology Associates of Tarrant County (RATC), Fort Worth, Tex, built such a center for the nine hospitals that RATC covers. In effect, RATC established an in-house dayhawk and nighthawk, pulling physicians out of the nine hospitals and having them read at a single central location. The result eliminated RATC’s fractional needs for radiologists.

Elliott explained: “A hospital may have the need for two and a half radiologists, but it’s hard to split a radiologist. But when you cover nine hospitals like we do, we can have fractional share requirements if we bring some of that manpower in-house and squeeze out those fractional manpower needs and be more efficient. That also enables you to go after some dayhawk business, especially in the rural hospital markets where either they can’t get subspecialized radiologists in, or they’re temporarily without a radiologist at all in some cases.”

Elliott said that it would be difficult to justify the teleradiology center’s capital costs for a group that covers only a single hospital. However, he does believe that one could squeeze at least half a radiology slot out of a group covering as few as three hospitals. “The more hospitals you have, the more you’re able to do it,” he said.

Swapping for Rads

Institutions that cannot afford the capital upgrades or locums might consider physician assistants (PAs), who have subspecialized in radiology, or radiology practitioner assistants (RPAs). Although they too are in short supply, they will certainly be less expensive than recruiting and retaining an interventionalist.

In most states, neither PAs nor RPAs are allowed to perform final reads, but they are able to carry out minor procedures, including myelograms, paracentesis, thoracentesis, and fluoroscopies, all under the auspices of a physician.

Theoretically, both PAs and RPAs are able to perform the above tasks, but there are several differences between PAs and RPAs. PAs are generally more experienced with surgical and clinical procedures, while RPAs are most often radiology technologists with additional clinical training. Some believe that PAs are more successful with filling in for interventionalists because of their previous clinical training.

Another important difference between PAs and RPAs is that most states and payors will allow a radiology practice to bill for PAs, but there are different standards for RPAs that may deny reimbursement by payors under certain conditions.

According to Weiss, the potential lack of reimbursement for RPAs has not deterred their use in busy institutions. “I think the more productive hospitals and groups, even if they can’t bill for them, are hiring them because they’re still cheaper and they improve the efficiency of the radiologists. They realize that radiologists are in such demand that it’s worthwhile eating that cost.”

Corbett added: “If the RPAs can do four fluoroscopies in the morning, then the radiologist can read 25 MRIs. That’s much more valuable to the group to have the radiologists reading MRIs than performing fluoroscopies, or PIC [peripheral intravenous catheter] lines.”

As for long-term solutions for the radiology shortage, Rao said, “Institutions need to increase the number of residency slots in radiology. There has to be a national push for that.”

Editor’s note: For more information on this dilemma see the article “Making Quality the Differentiator in a Flat World” in our February issue.

Tor Valenza is a staff writer for  Axis Imaging News. For information, contact .