Anyone practicing radiology for more than a few years can attest to tremendous change within the field: New technology, new applications to existing technology, telecommunications opportunities that place us somewhere between the traditional film reader and the virtual radiologist, to name a few. On the financial side, growth in the number of imaging procedures has been tempered by declining reimbursement per procedure, global payment schemes, and, the scourge of radiology, the capitated reimbursement model.
At the practice level, the specialty continues to reside in the trough of a feast or famine cycle of available and qualified radiologists. For the foreseeable future, we likely will confront the reality of demand outstripping supply. To understand our future, we must look to the past and recognize that the origin of this dilemma is multifaceted. Most of the trends have roots in the last decade of the 20th century:
- Decade-old concerns about the future of imaging resulted in a dearth of residents in the mid to late nineties, now manifesting as fewer radiologists entering the work force.
- The Fear Factor in the proposed shuffling of the health care deck, a multiheaded monster, traces its origin to the early 90s and the specter of the proposed Clinton health care initiative; subsequent legislation designed to slow medical care inflation through budget neutrality; the emerging concept of the gatekeeper model for health care delivery; and, with the popularity of radiology among medical students reaching its nadir in the mid 90s, radiology training programs either trimming or eliminating their residency spots.
- Appreciation of assets and net worth in the equity markets altered the traditional period for retirement for older radiologists and led to a shrinking pool of experienced radiologists. The vacuum created by this trend is now in flux in part related to perturbations in equity markets beginning in 2000.
- Explosive growth in cross-sectional imaging, mammography, and an aging population consuming inordinate radiology resources have and will continue to mandate increasingly greater productivity from radiologists and technologists. Translation? Either work longer hours or improve efficiencies within a practice if the desired goal is retention of a similar level of compensation and benefits, including time off.
- An evolving work ethic. Younger radiologists in or recently out of training programs are reevaluating the balance between work-related activities and personal life. This phenomenon is not unique to radiology
A Perfect Storm
This perfect storm in diagnostic imaging has inflated the demand for radiologists, creating a feeding frenzy for those entering the specialty and, among practicing radiologists, financial opportunities unheard of 5 years ago. Forget the theoretical implications: the practical consequences are borne out in the following anonymous examples reported to me of radiology conduct in the 21st century:
1. A fellowship-trained radiologist joined a practice as an initial hire. He received a generous compensation package, a signing bonus, a short track to partnership, and an opportunity to participate in equity opportunities. Within one month of starting, this individual announced that he was leaving the practice. His complaints? He proclaimed that the practice imprisoned him in his home. In reality, his workday began at 9 AM and ended about 5 PM. Call was every fifth weekend and one evening per week with nighthawk coverage after 11 PM. The radiologist indicated he would be willing to stay provided he received a significant increase in salary and an even shorter track to partnership.
This radiologist was marginally productive, did not generate revenue to match his salary and benefits, and was woefully inexperienced, lacking the maturity and poise to deal with clinicians and his colleagues. Other radiologists in the department of radiology were frequently compelled to review this radiologist’s work and analysis. During the exit phase of this individual’s employment, he proclaimed that the perfect job was interpreting 30 CT scans per day, less call, and more vacations. He indicated that he could command a starting salary of $500,000.
2. In a different situation, a practicing radiologist determined that there was no future with the practice. Unrealistic and constantly shifting demands from this prospective partner resulted in protracted, expensive, and acrimonious negotiations. The concept of partnership with a marginally productive radiologist comfortable only in an outpatient environment and loath to do a full day’s work created tension and an uncomfortable working environment between this individual and the other radiologists in the group. One cannot underestimate the fractious and divisive environment when individuals place their needs and demands above those of the practice; in this instance, someone accustomed to arriving late and departing early.
This practicing radiologist bristled at the notion of improving productivity and expanding a limited skill set. The notion of team player was anathema to this physician. In circumstances like these, it behooves the doctor to look for greener pastures. Such was the outcome in this case.
I am certain the subscribers to this journal can relate to these types of general experiences with similar ones of their own. Unrealistic expectations, poor performance, unacceptable productivity. We all feel helpless when circumstances beyond our control wreak havoc in our businesses. In my estimation, this is a symptom of an insidious disease prevalent in radiology. I deem it the syndrome of instant gratification based on the illusion of need or worth. Others refer to it as greed. In reality, this is a trend driven by market forces we have little control over; a market where demand far exceeds the pool of radiologists.
My naïve side bemoans these circumstances and yearns for the good old days: fee for service radiology, generous compensation, shorter workdays, and an abundance of time off. The business side of me prepares for the present and future of radiology in a manner similar to that of my friends in other small businesses where economic uncertainty, and economic periods of expansion and contraction batter the small businessman regardless of the sector in which they operate.
Here is a list of suggested strategies for the uninitiated:
1. A practice should be in a constant state of recruiting. The pleasure factor of this task falls somewhere between a barium enema and Chinese water torture
2. Look at alternative avenues of recruitment, beyond the prevailing practice of recruiting from residency and fellowship programs. Our experience indicates that recruiting physicians already out in the work force has the following advantages:
- Proven track record in the verifiable references from prior working experience
- Realistic expectations for compensation and benefits
- Maturity and experience. Most radiologists out in the world of private practice and to a lesser degree in academia understand the unwritten rule of providing service, responding to the needs of referring clinicians, and a work ethic unmatched by that of radiologists emerging from the protected environment of training.
This approach, however, is not without predictable pitfalls. On more than one occasion, failure to adequately investigate references and other aspects of the due diligence process created problems. The emotional side of the recruiting game and a short-term need to provide coverage occassionally overpowers common sense and discipline in the recruiting process. For example, a practice facing expansion had the daunting task of hiring at least six radiologists in a one-and-a-half-month time frame. The principals of the practice spent the better part of the summer negotiating with (among others) a radiologist desirous of fleeing the academic world for the private practice milieu. The radiologist’s expectations and demands were not consistent with the real world. The gap between the inflated sense of self-worth and the true value to the practice became evident as the negotiations (and legal fees) dragged on. In this instance, the practice would have been better served by cutting bait rather than to continue fishing for an unrealistic catch. The practice encountered similar circumstances on a prior occassion and finally learned its lesson. The practice is now reluctant to seek out those from the sector known as the ivory tower.
3. Constant assessment of existing lines of business. The traditional approach to private practice supports the status quo. In my experience, this is a recipe for disaster. There is a time for expansion, maintenance of existing business lines, jettisoning of unprofitable components of an enterprise, and eliminating unproductive employees. This is by no means the gospel or a call to arms. Rather, I would suggest that practices continually look at themselves as a business, subject to the vagaries of any sector of the economy. An increasingly expensive work force, operational and philosophical inertia, and a constantly changing market with new and increasing challenges demand an innovative approach to survive in a constantly changing world. Beyond survival, opportunity and success beckon.
Howard Kessler, MD, is chairman, department of radiology, Holy Redeemer Hospital and Medical Center; president, Pennsylvania Radiology Group and affiliated practices; and a member of the Decisions in Axis Imaging News editorial advisory board.