Applied Radiology

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

This title is an old joke that gets bandied about whenever the job market in radiology becomes “more competitive.” Imagine the horror of carrying around a sandwich board through the streets looking for a few films to interpret that no one else is interested in. Are we there yet? I think not, but clearly the market is tight for jobs in our specialty.

Why is that the case? I feel certain that everyone knows at least some of the story, assuming one has paid any attention to the world since2008. We had the second worst “crash” in the stock market since the Great Depression. It was created largely by the debt burden of virtually unrestricted lending in the housing market made worse by major banks selling this nicely decorated bad debt all over the world. Unemployment remains stubbornly high with no clear improvement in sight. While the U.S. economy has rebounded from the steep recession, it remains essentially stalled. The specter of another economic swoon crops up every other day in the press. The huge U.S. budget deficit isnot being addressed and holds the short and long-term economic future of our country hostage. The entities that pay for our services are constantly cutting back reimbursement with more cuts to follow, likely far more draconian compared to what we have seen thus far. Congress seems to have terminal constipation in passing legislation to address our economic issues (and many others for that matter), continually shirking its fundamental responsibilities to the nation for personal and party political expediency.

Europe is in a morass of economic strife from overwhelming debt in several member countries, only now being partially addressed, that threatens the existence of the current world financial structure. The world’s other major economic driver, China, has slowing economic growth as its customers stop buying the plethora of products the country sells. Otherwise, everything is just peachy.

The erosion of radiology’s traditional service base, both diagnostic and procedural, continues unabated. Large academic institutions and “nighthawk” services compete with private-practice groups for after-hours interpretation and in some cases sell their services at all hours for nonprocedure-based study interpretation. These larger practice entities are immediately available, potentially offer subspecialty-level interpretation, and are cost competitive based on scale of service and a lower expected salary structure than private practice. This development is a natural outgrowth of the commoditization of radiology brought to you by the double-edged sword of electronic transfer and storage. Self-referral for radiology services is out of control and by far the fastest rising cost component of imaging reimbursement, but one that few governmental agencies or payers seem interested in interceding.¹ Given all these conditions,who can blame established practices, both academic and private, from manning the walls and keeping the drawbridge up? Salaries and benefits are the most expensive costs in a practice. Also, the hair-trigger volatility of the financial markets has forced “retired”radiologists back to work, and who can blame the current population of retirement-age radiologists from biding their time while looking for safe, stable investments with returns that can just, at best, keep up with inflation, which fortunately remains under control at the moment. The guarantee of a high-paying job most people going into medicine, and perhaps particularly into radiology, expected is on shaky ground.

While conditions for securing an ideal position are not great, we have certainly tread on similar paths before. I think that the situation the nation finds itself in now is not a typical “down” business cycle; rather clearly something more difficult and less transient than that, but such business cycles are still superimposed on overall macroeconomic situations. In other words, some things will improve even when the overall economic picture is not terrific. This is my opinion and not the insight of an economist, whatever those are worth. A stable or slightly improving economy coupled with the continued aging of the work force and disgust with the ever-growing workload will drive more radiologists into partial or complete retirement. Hopefully, new technologies will arise or expand to create more job opportunities as we saw with computed tomography (CT) and magnetic resonance imaging (MRI); perhaps these developments will not be the game changers they were,but they will help.

We must give thanks to the malpractice lawyers who keep us so busy ruling out everything. They create enough anxiety in our referring colleagues to keep the anodes rotating day and night. We need them as much as they need us.

Jobs are, of course, still out there. To get one you need to optimize your training within reason and establish yourself as a hard-working,dedicated, caring doc in your current environment. Expect to look longer and harder and probably to take a position less-than-perfectly suited to you. You may live in a place that is not your personal Garden of Eden, but it may grow on you. You will probably need to consider a lower starting salary than expected and a partnership may be farther off than has been traditional. Be willing to be flexible and separate real requirements from desires. Don’t be married to any expectation that current circumstances may force you to divorce.

There is another item that worries me about the current state of the radiology job market. We must not “eat our own.” When I talk to finishing residents and fellows about their job searches I hear some disturbing comments. These concern interviews where they were treated disrespectfully and told how lucky they were just to be invited. I have seen advertised and heard about job offers that were composed of the most undesirable parts of a practice that no one else in the group wanted to cover. Fellows have been offered positions where they were specifically told they would not have an opportunity to work in their area of specialization and other jobs where specialty skills in multiple simultaneous areas (like mammography, ultrasound, and neurointervention) were required. Salary scales were lower and work demands higher than had been traditional for given practices.

If we are to have any long-term existence as a specialty, we must have each other’s backs to some degree. While radiology practice, like all medical specialties, is at root a competitive business, in my career I have generally experienced a high level of camaraderie and mutual support among us. Perhaps we all recognize a special vulnerability we feel from larger medical specialties chipping away at our traditional“turf” and the potential for easier regulatory manipulation by governmental agencies given our relatively small numbers compared to most other specialties and therefore lack of political influence. While in general radiologists have held the line pretty well, cracks are beginning to appear as more pressure is applied, exacerbated by the current economy. The wider the cracks become the less we will be able to preserve the specialty as we practice it now. We must realize that we are all in the same boat and try our best not to alienate each other. This may require being less competitive, more collaborative, and perhaps even coping with decreased income for a time. Certainly not a popular idea,but one that may help us ride through this storm with less destruction until things get better. And in time, they will.

References

1. Kouri BE, Parsons RG, Alpert HR. Physician self-referral for diagnostic imaging: Review of the empiric literature. AJR Am J Roentgenol. 2002;79:843-850.