The relationship between an academic department of radiology and its parent teaching hospital and/or medical school is much different than that between a private radiology group and a community hospital with which it contracts. As an academic department of Thomas Jefferson University Hospital and Jefferson Medical College, the radiologists do not have a contract that can be terminated. Every academic center must have its own radiology department, and the staff therefore is part of a permanent marriage. Individual faculty members, from the chairman on down, can be terminated, but the department as an entity continues indefinitely. This is both an advantage and a drawback of the academic model.
The Department of Radiology at Jefferson consists of 32 full-time faculty radiologists and eight others who are part-time. In addition, we have eight PhD or MD faculty members whose role is primarily research. Our MD radiologists are all highly subspecialized and are organized into eight clinical divisions: breast imaging, cardiovascular/interventional, neuroradiology, ultrasound, body CT, body MRI, nuclear medicine, and general diagnostic. The general diagnostic division is further subdivided into chest, gastrointestinal/genitourinary, and musculoskeletal sections. Pediatric radiology is covered through a subcontract with the radiology group at DuPont Hospital for Children, which is the primary pediatric facility of Thomas Jefferson University. As can be noted from this divisional structure, the department is organized somewhat more along modality lines than organ system lines. That is largely a factor of Jefferson’s geography; it is a large hospital and the department is spread out in a number of different areas throughout the campus. This works as an advantage rather than a drawback, since it makes it easier to find space for expansion. About half of our radiologists work in more than one clinical division. Unlike most community hospitals, Jefferson does not have any general radiologists who perform all types of clinical imaging. We perform approximately 280,000 studies per year.
Much of the decision-making emanates from department committees. These include education, research, computer, picture archiving and communications system (PACS), residency selection, quality assurance, and contrast committees. There is also a chairman’s advisory committee, part of which is appointed by the chairman and part of which is elected by the faculty at large. The advisory committee meets with the chairman monthly and discusses major policy issues, as well as faculty appointments and promotions. Sometimes it meets separately without the chairman. Each clinical division has a director and the division directors also meet as a group with the chairman once a month. In addition to these committees, a very useful management tool is a daily meeting at 8:30 am between the chairman and Victor Sarro, our administrative director. Any faculty member who has an administrative issue or problem is encouraged to share it at that meeting. Those daily meetings allow us to address rapidly any problems that may have surfaced within the past day or two.
COMPENSATION FORMULA
Faculty compensation has two components: a base salary and an incentive bonus. The bonus is based on productivity, which includes a variety of elements-clinical workload as measured by professional relative value units (RVUs), rapid report turnaround, amount and quality of teaching (all residents and fellows are asked to evaluate their clinical rotations in writing), research publications, research grants, outside speaking engagements, service on department committees, department administrative responsibilities, and leadership roles in national organizations. Some other academic radiology departments use a very complex point system as a basis for incentive bonuses, but Jefferson does not. At the end of each year, each faculty member fills out a written report detailing all of their activities and meets individually with the chairman to discuss the report. That is the basis for the bonus. The department gets some salary support for faculty members from the hospital through Medicare Part A, and as a result of that and a successful clinical practice the department has been able to keep faculty incomes at very satisfactory levels, judged by the annual income surveys of the Association of American Medical Colleges.
As is the case just about everywhere in radiology, the past few years have seen major changes. Philadelphia has become an extremely competitive medical marketplace, and it is dominated largely by two major insurance carriers. Reimbursements to both hospitals and physicians have decreased. It is considerably harder now to obtain needed capital budget items from the hospital administration than it was 5 or 6 years ago. Because of reduced professional reimbursements, faculty members have had to take on increasing clinical caseloads to maintain their incomes at the desired levels.
COUNTERING DECLINING INCOME
The department’s primary strategy to make up for decreasing reimbursements has been to go after new business aggressively, through contracting with outside corporate or privately owned imaging centers. The department currently services contracts with two freestanding MRI facilities owned by one company, one MRI and one full modality imaging center owned by another company, an open MRI unit jointly owned by a third company and Jefferson Hospital, and a neuroimaging facility at another hospital, and will be taking on additional contracts with two more MRI facilities owned by physician groups during the next year. These outside contracts have stabilized the department financially and enabled the department to keep faculty incomes at favorable levels, but the motivation is not just personal gain. Substantial portions of outside income are directed toward maintaining the department’s research and teaching programs. In negotiating with the outside entities, it is helpful to emphasize the aforementioned subspecialty expertise the department can offer, as well as the national reputations of a number of our faculty members.
All of the faculty is involved in resident and/or fellow teaching to various degrees. About 90% of our MD faculty members are also involved in research. Obviously some are more productive than others, but everyone is involved. Research and teaching are probably the main reasons most of the radiologists at Jefferson are in academics; everyone appreciates the intellectual challenges and stimulation to which they are exposed every day. Many on the faculty started academic careers believing they would move eventually to private practice, but got hooked on the professional satisfaction derived from discovering new knowledge, developing new techniques, and finding new ways to improve patient care.
In spite of the demands of a highly competitive environment and the need to assume an increasing clinical workload, the department has worked hard to maintain our research productivity and has for the most part been successful. Last year our faculty produced 302 publications, consisting of journal articles, abstracts, book chapters, and textbooks. We had 18 active grants or subcontracts from the National Institutes of Health or other federal sources, 14 from foundations, and 43 from industry. These grants brought in slightly more than $4 million in funding. At the 1999 Radiological Society of North America meeting, department faculty and trainees participated in 61 presentations. Maintaining and improving research capability and the quality of teaching programs while facing an ever-increasing clinical workload is one of the major management challenges facing just about every academic radiology department, including ours.
ROLE OF PACS
An important asset in handling the outside contracts referred to above has been PACS. About 4 years ago, the department formed a committee headed by a physicist that evaluated the many systems on the market. We eventually chose a vendor and are now using its two-monitor workstations to read all of our MRI and CT studies. These include the studies that are sent electronically from all off-site commercially owned imaging centers. The system was installed 3 years ago and with the help of the company has received a number of operational upgrades. There are plans to extend the PACS to our ultrasound division in the near future.
Rapid turnaround of reports is another major challenge. After hearing many conflicting reports on the relative advantages and drawbacks of voice recognition systems, the department has chosen not to implement that technology yet.When the technology improves a bit more, voice recognition will be implemented, as one component of the all-digital radiology record.
Hospitals are under increasing pressure to reduce length of stay, and this means the department is inexorably approaching 24/7 radiology, even for routine studies. Providing such coverage is another major management challenge. A visitor can walk through the hospital at virtually any time of any night or weekend and find one or more of our faculty radiologists working with residents or fellows on performing imaging studies or interventional procedures. A number of the department’s clinical services are running routine readout sessions on Saturdays and Sundays. This, of course, creates further stresses and strains on both faculty and trainees.
Most academic radiology departments around the country are facing the same problems Jefferson faces. Although academic incomes tend to be somewhat lower than those in private practice, the gap has narrowed in recent years, and whatever deficit remains is more than made up for by the excitement and satisfaction of an academic radiology career.
NOTE: This is the second in a series of articles on new practice models in radiology. Part I appeared in the January/February issue.
David C. Levin, MD, is professor and chairman, Department of Radiology, Thomas Jefferson University, Philadelphia, PA.
