Dr. Casarella is a Professor and the Chairman of the
Department of Radiology at Emory University School of Medicine,
Atlanta, GA.
Many academic radiology departments are having difficulty. At
first glance, this statement seems paradoxical. Certainly the
business of radiology is booming. The number of imaging and
interventional procedures continues to grow at approximately 5% per
year. National Institutes of Health (NIH) research funding is
growing at 20% per year and, for the first time, a single
department exceeded $15,000,000 in NIH grants in 2000. Several
departments have total research budgets in excess of $25,000,000.
Applications for residency programs have increased dramatically as
the job market for newly trained radiologists is perhaps better
than it has ever been. There are about 200 American medical school
graduates who were unable to find residency positions this year in
radiology. The quality of applicants is outstanding.
So, what's the problem? The manpower shortage for radiologists
has had a devastating effect on many academic departments.
Excellent junior faculty have been recruited into the private
sector lured by huge incomes and shortened paths to early
partnership. The number of residents choosing fellowship training
is declining, and serious shortages have developed in areas such as
breast imaging and pediatric radiology. At least one major
pediatric hospital affiliated with a university now has no trained
pediatric radiologists. As the number of faculty decreases and
clinical activity increases, the opportunities for academic
pursuits have diminished. Given this trend, the benefits of
relatively low-paying academic jobs are erased and more lucrative,
increasingly similar private practice positions become more
attractive. Once the academic lustre is gone, so is the appeal of a
faculty position. As clinical growth continues, our ability to
accommodate it is diminishing. This provides opportunities for
others such as orthopedists, neurologists, cardiologists, vascular
surgeons, nephrologists, and emergency physicians to acquire turf
that is increasingly difficult to defend.
Without the teachers and cutting edge technology, how will the
academic programs be able to capitalize on the huge talent pool of
new applicants knocking on our doors?
The new Institute of Biomedical Imaging and Bioengineering at
the NIH is a tremendous benefit, and clearly our best departments
will be able to take advantage of it. However, of our 125 medical
school departments and 70 community-based residencies, only 25 or
so are positioned to build strong research programs over the next
decade. Even in those departments, much of the research is
conducted by PhD scientists or MDs from different disciplines. The
vast majority of our MD radiology trainees choose the more
appealing lifestyle of private clinical practice, and our MD
faculty are fully committed to clinical obligations. If the trend
continues, the specialty will gradually weaken from within and be
unable to ideally train the subspecialists that maintain the
quality and innovation that have been the hallmarks of radiology
for the past 30 years.
The situation is caused partly by the critical financial
condition of many of our academic medical centers. Operating
margins have dropped from 6% to <2% in 5 years, and capital
spending has decreased. Hospitals have become more frugal, and some
universities have merged or even sold hospitals in the hope of
financial efficiency. All of these fiscal issues have compromised
the academic environment.
What are some solutions? First, we have to restore the 70 to 100
residency positions lost in the almost monomaniacal drive toward
primary care that the medical schools championed over the past
decade. Second, another initiative would be to encourage some of
our most qualified, large private practice groups to develop new
training programs. Some of the 30- to 50-person megagroups are
filled with highly trained subspecialists who would be excellent
mentors and teachers. Adding residency training to more community
hospitals would also generate HCFA/GME income for the institution
and ensure a supply of new partners for the future of the
practice.
Third, the academic departments have to take full advantage of
the inherent efficiencies of digital technology in managing our
departments by implementing picture archiving and communication
systems (PACS) and filmless imaging on a system-wide basis. This
technology has the potential to significantly increase efficiency.
Most practices report a 20% increase in productivity with PACS.
Fourth, the academic departments of radiology will need more
resources from their respective medical schools. Until the present
time, most schools have viewed radiology as a lucrative
hospital-based specialty that did not require significant academic
resources. However, as the hospitals have suffered financially,
their resources are not as available to radiology. Medical school
hard money budgets, research space, and more revenue from endowment
resources will be required to keep the academics in academic
radiology, and to allow us to capitalize on new NIH-funded research
opportunities. Partnering with departments of biomedical
engineering is an attractive option for imaging research.
Fifth, we should, as a specialty, review our training
requirements in light of new practice environments to ensure that
our trainees obtain relevant experience in the most efficient time.
For example, can we incorporate sufficient breast imaging and
pediatric experience for interested residents to acquire expertise
within the regular 5-year training program rather than requiring a
fellowship ?
Many of the great departments will be successful in maintaining
their positions. However, the average departments will have more
difficulty. Their continued success is critical to the future of
radiology.