Some worry that radiologists may be in a fight for survival as a separate specialty. Experts weigh in on the changing field and what?s needed in the way of leadership.

The Darwinian theory of evolution has been applied to many situations outside of biology—say, for instance, professional advancement. Changing situations and politics in the workplace can result in “catastrophic events,” such as declining profits, rising expenses, and layoffs. The result is the extinction of metaphorical dinosaurs. Medicine is no exception.

Those who adapt well often find it easier to achieve their professional objectives, while those who are inflexible typically have difficulties advancing their career path. Sometimes the challenges are bigger than one person can handle alone, but enduring groups find their way through with leadership and collaboration.

This is where radiologists now find themselves. Three years ago (in 2007), radiology was the fifth specialty choice among medical students; last year—though still in the top ten—it fell to ninth place.1

And it may fall further if opportunities continue to shrink. A study published in the Journal of the American College of Radiology found that the ratio of radiology job listings to job seekers has decreased steadily over the past decade, falling from 3.8 in the 1990s to 0.60 in 2008.2

There are numerous factors driving this trend, from the economics (eg, rising and then falling reimbursements) to the clinical (eg, increased subspecialization among radiologists) to the technological (eg, new modalities and expanding information technology). All three have influenced the growing role of teleradiology and the corresponding commoditization of the radiology discipline.

Radiologists now risk extinction through absorption into other fields or outsourcing; the general radiologist has already become an endangered species. But experts believe that with leadership, foresight, and adaptation, the profession can bounce back.

Evolutionary History

When Leonard Berlin, MD, FACR, first entered radiology as a medical student/part-time x-ray technician in 1956, there were plain films—and that was all. But it was enough for the time—in 1956, black-and-white portable televisions had just hit the market, the oral vaccine was developed for polio, and IBM invented the first hard disk. “Nuclear medicine started in the mid-50s, but it was pretty rudimentary in those days,” Berlin said.

Fast forward to 2010. Berlin is now vice-chair of the Department of Radiology for Skokie Hospital of the NorthShore University HealthSystem, located in Skokie, Ill; a professor of radiology at Rush University Medical College in Chicago; and a member of Axis Imaging News‘ Editorial Advisory Board. “I’ve seen a tremendous amount of change,” Berlin said.

Radiology now includes not only x-ray, but also new modalities such as ultrasound, CT, MR, PET/CT, mammography, and PACS. “Plain films, which were 100% of our practice in those days, are probably now down to about 10 or 15%,” Berlin estimated.

The new technology has helped to shorten the time to a diagnosis, amplifying imaging’s clinical value. Physicians, therefore, have increasingly relied on images, and a cycle has evolved between growing value and greater demand. Diagnostic radiology is now growing at a rate of about 20%.3

With imaging utilization on the rise, these not-inexpensive technologies have commanded a larger portion of the health care budget. Approximately $100 billion is spent on imaging in the United States annually, and this cost is expected to double within 4 years.3 With health care costs, in general, under scrutiny, radiology has become a target for budget reductions.

At the initial launch of new imaging technologies, reimbursement rates seemed fair, even lucrative, and physicians began to view medical imaging as a new revenue center. Clinicians specializing in disciplines outside radiology, such as cardiologists and orthopedic surgeons, purchased imaging equipment and set up self-referral radiology options. Driven by the tremendous diagnostic value and, some would argue, the financial conflict of interest, this less-restricted use of imaging is seen by many radiologists as the source of excess and expensive radiological testing.

“So where we are today is adding tremendous value, but there’s confusion as to how to pay for that and where to go from here,” said Giles W.L. Boland, MD, vice-chair of the department of radiology for business development at Massachusetts General Hospital in Boston and an associate professor of radiology at Harvard Medical School.

Climate Change

Giles W.L. Boland, MD, Massachusetts General Hospital

As radiologists deal with the evolution of their own profession, they must also deal with the societal transformations impacting the medical community as a whole: the population in the United States is growing larger, life expectancy is getting longer, and the Baby Boomers are growing older. This has meant more demand for health care, with a subsequent rise in imaging acquisition and a more immediate need for image interpretation.

Recalling his early days in radiology, Berlin notes it was very unusual to have to perform an emergency read in the middle of the night. More often, exploratory surgery was utilized. But as advanced imaging technologies have replaced invasive diagnostic methods, radiologists have been asked to read more.

Subsequently, radiologists’ work schedules have changed. Rather than the 8-to-5 workday that was typical in early years, radiologists now find themselves on call. “It’s a rare hospital in the United States [today] that doesn’t have radiology coverage 24 hours a day, 7 days a week,” Berlin said.

With technological advances undeniably increasing efficiency and diagnostic value, radiologists have seen their workload increase rapidly. “The number of radiologists has not increased at the same rate as the number of imaging procedures,” Berlin said.

Technology—Boon or Bust?

So while technology has been a boon to radiology, it has not come without its challenges. “We are able to arrive at critical diagnoses much more rapidly and accurately, but our work is not necessarily easier or more rapid. The fact that we are able to make a more rapid diagnosis closer to the time the patient actually presents with symptoms is done at a price of more work,” said John A. Patti, MD, FACR, vice chair of the Board of Chancellors of the American College of Radiology (ACR).

Patti compares a 1994 chest CT to one taken today: the older CT contained about 50 images; the present-day CT exam can feature more than 250. “Clearly, it’s not easier or faster [to interpret a 2010 chest CT] than it is to interpret that 1994 chest CT,” Patti said.

But the advanced technology reveals more. “The sensitivity of the CT and MRI is astronomically higher than plain x-ray. You can have a third of a bone destroyed, and yet, when you look at the plain x-ray, it looks normal. Then, you look at the CT and the MRI, and there’s no question,” Berlin said.

It has also become easier to access, visualize, and share images. With the development of PACS, radiology went electronic. Physicians can now access radiologic “films” from almost anywhere—within the hospital, from home, at the office, or in the operating room.

“That’s just a phenomenal advantage. So really, it’s the technology that has driven the major growth in imaging whether it’s the better and faster machines or whether it’s our ability to use those machines more effectively, productively, and scientifically, but the challenge now is to take it to the next level,” Boland said.

Extinction Events

The next level will put technology to work for radiologists. Physicians and patients have seen tremendous benefits, but radiologists have wandered into dangerous waters.

Connectivity has actually resulted in greater radiologist isolation. “Only on rare occasions now—about 10% of the time—will the clinician come down to the x-ray department to consult with a radiologist, and so I think there’s been an unfortunate loss of radiologist-attending physician exposure and communication,” Berlin said.

Radiologists have also grown apart from each other. “We face the possibility of disaggregation, driven by the need for subspecialty expertise. If not handled correctly, this could lead down the road to the absorption of radiologists into clinical service lines that are controlled and managed by other nonradiologist physicians, hospitals, or even for-profit corporate entities,” Patti said. This, the ACR notes, will have a strong impact on private practices.

“Smaller groups are finding it harder to survive on their own because they don’t have the bandwidth or the expertise to cover the whole range of services that imaging can now offer,” Boland said. Teleradiology has not helped in this regard, but rather has contributed to the commoditization of radiology, according to many.

Teleradiology seemed a boon at first, because it alleviated the inconveniences of on-call service. But eventually, it posed the question of “Why only at night?”

Although teleradiology is beneficial for small hospitals that don’t have access to subspecialty radiologists, its ubiquitous use is endangering radiologists in private practice and hospital facilities. The use of teleradiology companies to cover night shifts has had its own evolution—driven by profit and competitive demands, these services have expanded into daytime and subspecialized reads.

Berlin notes their pitches often suggest less expensive, instantaneous, 24-hour coverage that can allow a hospital to reduce its radiology staff and the amount of money budgeted for their salaries. “Hospital leaderships have signed up with these teleradiology companies because they can do it cheaper and more efficiently. So we had short-term gain for long-term pain,” said Berlin.

Survival of the Fittest

To minimize that pain (and avoid extinction), radiologists must come together behind leaders with the foresight and capability to notice and act on trends impacting the industry. “I think we as radiologists need to refocus and energize ourselves around leadership and what it means to be a good leader,” Boland said, adding the definition of good leadership remains the same no matter the industry.

Generic leadership qualities include vision, charisma, intelligence, adaptability, flexibility, a company focus, lack of a personal agenda, the ability to care about and mentor employees, delegation skills, a motivating work ethic, and a commitment to service. For radiologists, this means patients are always top of mind. “It should serve as a guiding principle and the bedrock for leaders at all levels—leaders at the group level, the health care network level, the state level, and the national level,” Patti said.

The ACR has established programs to nurture leadership within radiology, working alone and in conjunction with other organizations, such as the Radiological Society of North America (RSNA) and the American College of Physician Executives (ACPE). “We’re in the early stages of developing a core curriculum for residents, which we hope will reestablish this culture of service beyond clinical diagnosis and treatment. There is so much else a radiologist provides in terms of value to the health care enterprise beyond just interpreting the images,” Patti said. A commission on practice development and leadership has also been formed.

One thing that is certain is that radiologists need the support of colleagues and administrators to achieve their goals. In many cases, leaders require resources, even when acting on a volunteer basis. “One of the cruxes of our challenges right now is to promote, encourage, and direct physician leaders into these roles—support them such that they can set the tone and the direction of where we need to go,” Boland said.

To MBA or Not to MBA?

One of the resources radiology leaders require today is business intelligence, both the tools to collect and analyze data as well as the ability to implement action based on that intelligence. Radiologists have been late to the game in using information technology to drive quality improvement in practice.

“We need to fundamentally understand that we are, in many ways, no different than traditional businesses: we have customers; we have products; we have services. So how do we enhance value and bring that increasing value to customers, who are ultimately patients but also referring physicians?” Boland asked.

Answering his own question, Boland cites strategies such as rethinking and reinventing the profession as well as tangibles that include new products and services. At the same time, neither customer service nor quality can suffer. “There are probably 100 data points that one can actually look at in real time in terms of quality, service, throughput, revenue, efficiencies, demographics, marketing strategies, etc,” Boland said.

And while a business degree is not required, for those radiologists interested in leadership positions, it certainly doesn’t hurt. Whether or not they have the degree, they will need the information. “If you go back to the 1960s and 1970s and look at department chairpersons, generally, they were chosen on the basis of academic and scholastic achievements. Now, people look for business acumen,” said Berlin.

With changes in reimbursement, radiologists are even more challenged to enhance their revenue stream, particularly those in larger institutions. Those in independent practice will also need to adapt and modify business models. “There are a lot of people who want to do what radiologists do and not necessarily because it produces income, but because of clinical value. And we have really emerged into a very fierce, competitive environment in which imaging and the people who do it are increasingly regarded as commodities,” Patti said.

And though the future is uncertain, it can be bright. “I still believe that imaging is so critical and valuable to patient care that it needs to be performed, run, and read by people with an intimate knowledge and skill of what it takes to provide high-quality images and promote that service in a business-like fashion,” Boland said.

Boland does expect to see some casualties but believes that for those with the right approach—one involving foresight and flexibility—there is still tremendous opportunity. “I think it’s still a very good future for radiologists and imaging departments who have the right attitude,” Boland said.

Renee Diiulio is a contributing writer for Axis Imaging News.


  1. Radiology Association of North America Inc. Early radiology exposure could lure medical students to specialty. RSNA News. August 2009. Available at: Accessed February 5, 2010.
  2. Sunshine JH, Maynard CD. Update in the diagnostic radiology market: findings through 2007-2008. Journal of the American College of Radiology. 2009;5(7):827-833.
  3. Duford D. Diagnostic radiology costs. The Self-Insurer. May 2009:26. Available at: Accessed February 5, 2010