Guest Editorial: Radiology at the crossroads

Dr. Tehranzadeh is a Professor of Radiology and Orthopaedics and the Director of Musculoskeletal Radiology, Department of Radiological Sciences, University of California Medical Center, Orange, CA.He is also a member of the Editorial Board of this journal.

A doctor addressed his patient, "I have good news and bad news for you. The bad news is that we have to amputate your feet, but the good news is that the man in the next room has offered to buy your boots." For radiologists, the good news is that the national shortage of physicians in our specialty has elevated us to top-salary positions. Advances in PACS and teleradiology have made our lives easier and have provided us with exceptional employment opportunities. Since this is all so wonderful, you might be wondering what the bad news could be. I will explain.

With the stock market boom of the late 1990s, a large number of radiologists who had invested wisely opted to retire. This coincided with the 1997 Veterans Administration decision to reduce the number of speciality resident slots (including radiology), shifting many new residents to primary care. In a similar time frame, the Accreditation Council for Graduate Medical Education (ACGME) "cracked down" and closed several poor-quality radiology residency programs. While the pool of radiology specialists was shrinking, the aggressive introduction of new imaging technologies (eg, multidetector CT, PET, PET/CT, and high/low-field MRI) created greater demand for radiology services. Thus, a national shortage of radiologists was inevitable.

The development of PACS and teleradiology, in conjunction with the shortage of radiologists, has been a mixed blessing. On the one hand, there are more radiology positions available at higher salaries and improved benefits. On the other hand, these technologies created a new breed of "traveling radiologist" (such as locum tenens, teleradiologists, and nighthawks). Locum tenens positions, which were once mainly occupied by retired part-time radiologists, have become attractive to junior radiologists. In fact, a radiologist can earn more money in a locum tenens capacity than as a full-time employed radiologist on a fixed salary.

As entrepreneurs in radiology and other medical specialties discovered that easy money could be made in the outpatient imaging business, they jumped on the bandwagon, and imaging centers popped up on street corners and in shopping malls. The accelerating shortage of radiologists also enhanced the loss of traditional radiology "turf," which led to a faster shift of ultrasound studies to obstetrics and gynecology, and cardiac/vascular angiography to cardiologists, etc.

Academic radiology research and development also suffered, as radiologists worked increasingly longer hours and, consequently, had less time for research and teaching. With the implementation of the Deficit Reduction Act, they need to work even harder to maintain their income levels. There is a trend toward decreasing attendance at radiology meetings, ¹ and fewer radiologists are participating in research and publication. ² Will this trend in academic radiology drive more residents into other areas of practice? Will junior academics opt for greener pastures? One might wonder what the point of an academic career is if you have to work as hard as you would in private practice, have little time or support for research, and earn less. This trend is further exacerbated in academic radiology departments as chairpersons increasingly monitor relative value units (RVUs). Staff radiologists become more concerned with their clinical productivity, thus negatively impacting their time spent on research or mentoring. Most hospital administrations covet RVUs well above teaching or research, and they substantially control financial support. It no longer pays to do research, publish, and teach. Despite the establishment of the National Institute of Biomedical Imaging and Engineering in the National Institutes of Health (NIH) by President Clinton in 2000, most academic radiologists do not have basic science research background (with a PhD), grant-preparation skills, or time to successfully compete for grants. Those few who have been successful now face NIH budget cuts stemming from post-9/11 events and the Iraq war. ³

U.S. radiologists are at this crossroad. If we continue to promote an environment of constantly chasing more dollars, if we continue to foster the development of the part-time, itinerant, and at-home nocturnal radiologist, and if we continue to sacrifice our efforts to keep improving our specialty at its core-the core that brought us to the enviable position in which we find ourselves today-we will surely see our specialty erode. All of radiology's local and national organizations, administrators, private and academic physicians, and even those with commercial interests have a huge stake in what happens now. The quality of research and teaching in American radiology will be at greater risk as the trends I have described play out in the future. The majority of U.S. radiologists are in private practice. Perhaps they do not believe that a decline in American radiology research and training quality or the lack of providing subspeciality radiology service is a risk to them. They would be very short-sighted in such a view. The training of future radiology residents and the quality and productivity of radiology research are very much in their interest. It is not just a problem for the academics to solve.

Perhaps someday American radiology residents will have to go to Japan or Europe to receive advanced training or do meaningful research. That outcome is in all of our hands now.

REFERENCES

1. Braley S. 2004 Meetings Market Report: Association meetings. Meetings Conventions. 2004;August:31-41.
2. Rahman M, Haque TL, Fukui T. Research articles published in clinical radiology journals: Trend of contribution from different countries. Acad Radiol. 2005;12:825-829.
3. NIH budget falls for the first time in 36 years. Available on the American Association for the Advancement of Science Web site: www.aaas.org/spp/rd/nih06f.pdf. December 22, 2005.