An article [Imaging Business] in this month’s Axis Imaging News describes very accurately the present manpower shortage in radiology and its causes very accurately. It does not, understandably, recommend remedies.
The basic difficulty is also a blessing: radiology has assumed an ever-increasing importance in diagnosis, selection of therapy, follow-up, screening, as well as image guided interventions. It has in the past decade continuously improved techniques, and each one of the cross-sectional modalities has matured, become more precise, and increased the number of images to be carefully read. It was during this same period that health policy makers decided that enrollment of beginning physicians into radiology, along with other specialties, needs to be discouraged in favor of primary care. Radiology may even have been singled out because of the high cost of individual pieces of equipment, without policy makers realizing that precise diagnoses save on expenditures by shortening or eliminating hospital stays.
This factor, in addition to the stepwise decrease leading to elimination of Medicare subsidies to teaching hospitals, also has helped to reduce the number of radiology training programs and either decreased or kept the number of radiologists finishing their training close to constant. Considering that the number of procedures performed per year has generally increased by close to 10% overall in each of the past 5 years, and that the procedures are requiring more time to interpret, as, for instance, helical and multi-detector CT scans, it is surprising that the shortages are not more drastic. It is understandable also why many older radiologists are keen on retirement. Radiology is no longer an eight-to-five occupation. Being on the firing line frequently at night and on weekends and holidays, having the choice and quality of examinations dictated by HMOs or insurance companies, performing a second-best or obsolete procedure on patients in order to satisfy the instructions of someone who has to approve the imaging examination can be discouraging.
Academic institutions are facing even more difficulties. Teaching hospitals are generally in deep financial trouble due to a combination of poor contracts with HMOs, progressively reduced reimbursements by Medicare and Medicaid, and the traditional culture of being obligated to take care of many underprivileged patients. The mere fact that teaching hospitals cannot be as efficient because of their educational function contributes an additional financial burden. As modern imaging equipment requires large expenditures and a constant investment in upgrades, it is, and increasingly will be, difficult for teaching hospitals to keep on the cutting edge of instrumentation. It is possible that we may in the United States face the situation already extant in India and South America. The good equipment is in private hospitals and offices, and though many of the private radiologists are holding honorary appointments in medical schools and their teaching hospitals, they often generously allow rotation of residents through their establishments in order to make it possible for residents to obtain a modern radiological education.
Because of financial constraints, most teaching hospitals in the United States allow clinical research imaging procedures (which must be approved by the Institutional Review Board) only if they are paid for, no matter when performed, this contributes to the decrease of good clinical research papers from the United States in leading journals and at Radiological Society of North America meetings.
Academic institutions cannot compete in income with private radiology, and lately many cannot even compete in quality of life. Being on the faculty of a teaching department used to be prestigious, and faculty members felt poor but noble, and, occasionally, famous. This is no longer true in most teaching departments.
What are the answers?
- Government leaders and Congress must be persuaded that saving on medical education and failing to support teaching hospitals will destroy one of the jewels of our culture, jeopardizing medical progress just as bench-to-bedside research bears fruit.
- The National Institutes of Health should reinvent the academic training grants that in the 1960s and 70s educated most of today’s leaders of radiology. These programs will make it possible for radiologists to obtain the necessary training to compete for research grants, making an academic career meaningful, not just private practice with a lower salary and more responsibilities.
- Medical schools and teaching hospitals should also be persuaded that it is in their interest to help radiology raise donated funds for the building and maintenance of research laboratories and the support of basic scientists. It is the cooperation between basic scientists in radiology departments and academic clinical radiologists that has led to the many exciting developments that we are enjoying today.
- Finally, to survive and be able to handle the ever-increasing number of images without increasing manpower, radiologists should insist that imaging companies and government agencies subsidize a crash program to develop computer aids for reviewing images, not to make diagnoses, which may be too difficult today, but to attract the attention of the reader to deviations from normal.
- Teaching programs must be enlarged, and quality preserved.
- Serious consideration should also be paid to shortening the basic training program if subspecialization fellowships follow.
The future is bright, in spite of the present threatening clouds, if we have the foresight and courage to implement changes.
Alexander R. Margulis, MD, is an internationally recognized radiologist who served for more than 26 years as the chairman of the Department of Radiology at the University of California at San Francisco. He is presently a clinical professor of radiology at Weill Medical College of Cornell University in New York City and attending radiologist at New York Hospital.