Applied Radiology

Dr. Mauro is the Ernest H. Wood Distinguished Professor of Radiology and Surgery and the Chairman, Department of Radiology, University of North Carolina, Chapel Hill, NC. He is also a member of the editorial board of this journal.

There are multiple well-defined decision points in pursuing a career path. The choice to attend medical school and become a physicianis a major one. By the end of the third year of medical school (or at the latest, the beginning of the fourth year), the medical student mustdecide on which field of medicine to enter-another major decision. By the third year of radiology residency, it is time for the choice ofa subspecialty fellowship. All of these choices are preparing the young physician for a career in radiology. But what type of career?Another choice must now be made. Does one enter the private sector (private practice) or become an academic radiologist?

Many academic radiology departments are having significant difficulties recruiting young dynamic faculty. Clearly, trainees interestd in funded research opportunities (NIH, etc.) naturally enter the academic sector. Sadly, we have too few of these individuals in ourtraining programs. But what about those individuals who are interested in clinical research investigations, teaching, and clinical work? The majority of research performed in academic medical centers is clinically based. These investigations are performed in conjunctionwith a busy clinical practice and are not often funded by external sources, but via the departments themselves. The majority of residenteducation (the most valuable part) is also accomplished in this apprentice-like environment. In the past, it was commonplace for undecided trainees to join academic departments as junior faculty to see if they were cut out for a life as academic radiologists. After 3 years or so, the young radiologists would be better able to decide. If they became infected with the academic bug, they would stayand enjoy a long productive career. If not, they had gained a tremendous experience as junior faculty and were heavily recruited in thecommunity. Many large subspecialized private groups specifically targeted the junior faculty ranks of academic departments for theirgroups. This was a win-win scenario for both sectors.

Today, undecided trainees are no longer entering the academic sector for a trial period. One concern expressed by trainees is that they donot want to have the pressure of publication. This pressure exists in the conventional tenure track. However, most institutions have created or are now emphasizing a "clinical or clinician-educator track."There is no pressure to publish on these clinical tracks. The expectations are clinical service and education. Faculty members on these clinical tracks are highly valued and are promoted rapidly through theacademic ranks (assistant, associate, and full professor). Another concern that has been expressed is the power and authority of a singleindividual-the departmental chairman. In the private sector, full partners have an equal vote-a democracy compared with the benevolent dictatorship in academics. In reality, the faculty of an academic department is its most valuable resource, and every decision a chairman makes is with the faculty's best interests in mind. So, why are academic departments having difficulties recruiting young faculty? Well,"it's the economy, stupid!"

By economy, I mean compensation. Simply put, you can earn more money in the private sector-quite a bit more. There are a number of reasons for this discrepancy. Payor mix and institutional taxes certainly play a role. Participation in the technical component of a radiology practice is commonplace in the community. This practice is just beginning to take root in academia. However, the most significant factor impacting academic compensation is the fact that education and clinical research are not reimbursed activities, yet they are absolutely critical to the future of radiology.

Without significant investigation being performed in departments of radiology, the major advances in imaging will be made by clinical departments. It will be only a short time until the entire practice of radiology will migrate into each representative clinical specialty. Basic and clinical investigations MUST take place in departments of radiology. This, in part, makes us a discipline and not simply a service. It is therefore incumbent upon academic radiology departments to support both basic and clinical research with time and dollars.

Academic departments represent the farm system for the private sector. It takes time and effort to teach medical students, residents, and fellows-time and effort that is not compensated. Although the majority of radiology residents are paid by the hospital via the federal government, it may be surprising to know that because of the GME cap placed in the 1990s, many resident and most fellow positions are paid through departmental funding. In these cases, departments are not only paying the salaries and benefits for these residents but are spending significant uncompensated time to train them as well. It is noteworthy that the overwhelming major beneficiaries of this training arethe private sector radiological practices who contribute little to the missions of academic departments.

Our system is broken, and we all will pay the consequences if it is not corrected. A failing academic radiology sector will lead to our inability to train young radiologists and perform research. In the worst-case scenario, if left unchanged, there will be no need for academic departments to train the next generation because there will be no independent discipline of radiology.