Applied Radiology

Dr. Mirvis is the Editor-in-Chief of this journal and Professor of Radiology, Diagnostic Imaging Department, University of Maryland Medical Center, Baltimore, MD.

My colleagues and I recently designed a new reading room adjacent to the Emergency Department, and I am glad we added plenty of extra countertop space. While the original plan called for two sets of PACS monitors and a CT workstation, during the 8 months since opening the new room, several more reading stations have made an appearance. There are monitors for reading federal government studies, and another set for reading studies from a recently merged private hospital. Other areas of the department have monitors for the Veterans Hospital next door and three private offices in which we offer interpretation services. To accompany the new hardware supporting these activities, a new section has been created, a section of "community radiology."

The community radiology section consists of full- and part-time staff who commute to sites away from the University Hospital. However, to some degree, all staff are involved in reading specialty studies from outside the main department. Ultimately, the outside studies will all be interpreted from one site in the department to maintain a more efficient process in acquisition, interpretation, and timely reporting.

Certainly, over the past several years, our mission as a classic academic radiology department has evolved. Historically, the main effort, as with most academic departments, has been to provide excellence in clinical service and perform scientific investigations leading to peer-reviewed articles, grants, promotion up the academic ladder, and other recognized benefits of academic success. In the recent past another goal has been added to this classic mission: survival.

Traditionally, in most major cities, academic hospitals have cared for the sickest and most complex patients, many with little or no medical insurance. These patients often present with disease processes that are quite advanced due to lack of preventative and general healthcare, as well as poor living and working conditions. Such patients frequently require the most intensive care and complex treatment procedures to recover. While, local, state, and federal programs offer some financial help to compensate academic centers caring for such patients, the pot of money is shrinking, and other priorities (ie, infrastructure, a prescription drug benefit, education, rebuilding Iraq, etc.) are competing for fewer dollars.

Even during flush times, when healthcare dollars were more available to help academic centers handle their particular patient population, radiology program graduates could obtain a far more lucrative salary and benefit package from private practices, which usually care for better-insured patients and perform a lot of well-care imaging. Still, there were enough graduates interested in academic careers who were willing to accept the salary difference. Sometimes there was even competition for academic positions. In the past 5 to 10 years, far more positions in radiology have become available in the private and academic sectors than can be filled by the pool of radiologists in the United States. Under these conditions, private practices are competing aggressively to attract talented radiologists, or perhaps any radiologist. Thus, the salary and benefit offers have risen quickly. Academic centers cannot even come close to competing with this rising salary curve. Thus, fewer individuals are willing to accept the growing salary difference and opt for the academic career they might ultimately prefer. Others perceive that the "economic good times" in medicine are fading and want to get their share before it's too late. Still others note an increasing workload on academics in recent years, often at or above private-
practice levels, and do not see any advantage to the academic path if there is no time to pursue the interests that attract one to academia in the first place.

Given these circumstances, it is prudent for academic centers to boost the bottom line, ie, to stay competitive at least among the academic candidates, if not those on the fence. It is unlikely that this revenue will be created from the traditional base of patient fees as professional reimbursements drop and the number of uninsured patients increases. Deans are struggling with cuts in state funding for education created by the recent and damaging recession, and they are not in a position to help. So, the only way to stay in the game is to be more efficient and seek new venues in which to provide service and, thus, more income. So the traditional academic radiology mission has been creeping, if not running, in a new direction.

Within the academic departments, many faculty members will begrudge the movement outside the boundaries of the medical center into the "real world" and the need to interpret studies outside their area of specialization. Others will go with the flow, understand the rationale, and strive to provide the best service they can to all parts of the department's more widespread operation. Even in the subspecialty areas, great cases can be found in every hospital. The community radiologist should be considered a full-class citizen of the academic department; after all, that radiologist could do essentially the same job elsewhere for a lot more income and may be bringing the most revenue to the department.

Finally, private practices in the community should not look upon the academic group with either anger or anxiety. The piece of the pie that changes hands will doubtfully be very large in most cases. Moreover, without the academic practice to train the radiologists of tomorrow, the private radiology practices would not exist, but would be composed of other nonradiologist specialists doing the same work. It is in the long-term interests of all radiology to keep academic centers strong and productive. Any revision in national healthcare policy must take into account the disparity in income between private and academic practice and move toward limiting that divide. Otherwise, many of our best potential researchers and teachers will never pursue the opportunity to do work that will benefit us all.