Guest Editorial: Do you do mammography?
Dr. McGahan is Vice Chair, University of California, Davis Medical Center, Department of Radiology, Sacramento, CA. He is also a member of the editorial board of this journal.
As I listened to one of my abdominal imaging fellows negotiate for his future private practice radiology contract, one of the first questions that his future employer asked was, "Do you do mammography?" The willingness to do breast imaging became a pivotal point of negotiations with his future group. The group wanted his services as an abdominal imager, including doing breast imaging, but he did not want to do mammography in his future practice. He finally negotiated that he would not perform breast imaging in his new job. I listened to another colleague in private practice who does full-time breast imaging complain that while his group is fully staffed in other subspecialties, there has always been a need for breast imaging staff within his group, with these positions remaining unfilled.
Many subspecialties in radiology have recently been producing an abundance of fellowship trainees. Recent trends indicate there are fewer job openings than applicants in certain subspecialties in radiology. However, the opposite is true for mammography, in which there are 2 to 2.5 job advertisements per job seeker. 1
Why is there such a national shortage of breast imagers? In speaking with our residents and future fellows, they are acutely interested in new developing modalities such as MRI. Within our institution (the University of California, Davis Medical Center), none of our residents in the past 10 years has chosen a breast imaging fellowship, until this year. Our graduates who choose private practice have tended to choose subspecialties heavily weighted in MRI and CT techniques rather than breast imaging. Other problems with breast imaging cited by some of our graduates are the potential litiginous situations, the repetitive nature of mammography, and the perceived lack of cutting-edge technology in this field. It seems that some of these problems may persist in the future.
Throughout the United States, the trends are not particularly good. A recent publication by Basset et al 2 showed that many breast fellowship positions were unfilled in 2002. There were 63 breast imaging fellowships filled that year-surprisingly, 13 fewer than in 1994.In phone interviews of senior residents, Bassett found that only 35% would consider a fellowship in breast imaging if one were offered to them. Their reasons were "not high tech," followed by "fear of lawsuits," and "too stressful." 3
There are those who take a different route to full-time breast imaging: migrating to breast imaging once in practice. Even Dr. Bassett switched from another subspecialty to full-time breast imaging because of a department need. At UC Davis, we are currently adequately staffed in breast imaging, but with retirement just around the corner for a couple members of our faculty, we are again inthe position of looking for new breast imaging faculty.
This future shortage of breast imaging at our institution and at institutions throughout the United States may exacerbate a problem with patient access to imaging of breast disease. Anxiety is great among those patients who have a screening mammogram and are called back for additional views and who then have to wait 2 to 3 weeks to obtain their diagnostic breast examination. This time delay is increased with a shortage of breast imagers who often have a full and busy work schedule.
How will this situation be remedied? Certainly, there must be some incentive for radiologists to perform breast imaging. Those general radiologists who have an interest in breast imaging may increase the percentage of their time in breast imaging. However, there are those who would argue that this is not the solution, as these are not fellowship-trained breast imagers and that "specialist" radiologists in breast imaging detect more cancers than general radiologists doing breast imaging. 4 True or not, until there are adequate numbers of full-time or fellowship-trained breast imagers, many general radiologists will continue to perform breast imaging. Will financial or other incentives help? Well, certainly if a radiologist cannot get his or her "ideal" job or location, he or she may seek fellowship training in breast imaging.
Perhaps interest in breast imaging will increase as residents are introduced to the newer aspects of breast imaging. Continued technical improvements in breast MRI will help. There is current research at our institution into CT and PET of the breast, which has increased the interest in breast imaging fellowships by the residents at our institution. Breast tomosynthesis is an up-and-coming modality that may make this field "more exciting" to trainees and help alleviate the problem of shortage of breast imagers. Until the perception of breast imaging changes, there may continue to be a shortage of full-time breast imagers for the near future. However, for the first time in many years, the number of applicants to breast imaging fellowships has increased. Maybe times are changing.