Dr. Shaw de Paredes is a Professor of Radiology and the Section Chief of Breast Radiology at the Medical College of Virginia of Commonwealth University, Richmond, VA. She is also a member of the editorial board of this journal.

Per aspera ad astra ..."Through the storms to the stars." This is what being a breast imager can mean. Radiology, in general, has faced a great challenge in maintaining an adequate workforce on both the professional and technical sides. Common discussion topics at our professional meetings relate to the understaffing of academic departments and the numerous open positions for radiologists in the academic and private sectors. Many facilities utilize locum tenens physicians and technologists from temporary agencies to manage the workload. As novel technologies and expanded roles for existing technologies develop, so have radiology services grown tremendously.

Breast imaging is a unique area of radiology for many reasons and, perhaps because of its uniqueness, these same workforce challenges are magnified. I am frequently called by radiologists who are seeking a new fellowship-trained breast imager for their practice. When our residents ask practicing radiologists what sort of subspecialty would be of benefit to their practice, the most frequent response has been mammography. Yet, fewer residents are seeking breast-imaging fellowships.

The unique aspects of breast imaging are multifactorial and can be viewed as both attractions and hindrances. Mammography is difficult and requires knowledge, skill, and great dedication to detail. Because mammography can be a screening examination, the impact on the patient in terms of her potential outcome is tremendous. At the same time, the radiologist assumes a high malpractice risk for missed cancers. With the expanded role of ultrasound and percutaneous breast biopsy, the radiologist has much more direct patient contact than in other radiologic subspecialties. The advantage is that the patient greatly appreciates this care, and the radiologist is often the individual who can guide a woman through a cancer diagnosis and management.

Mammography also has rigorous federal requirements for quality­­not seen in other areas­­that require great attention to detail and quality assurance. As new screening modalities, such as ultrasound and MRI, are introduced, we must make decisions about their value, utility, and how we are to cover these additional services as well. As the breast imager conducts all these activities with care, determination, and dedication, we find that we are often poorly valued and our work is poorly reimbursed. Breast imaging is often not considered a high priority area, partially because of the low reimbursement for mammography.

Then, why should a young resident just embarking on a career in a world of multislice CT, PET, neurointerventional imaging, and musculoskeletal MRI choose breast imaging? Why be challenged by the storms that breast imagers face? Here's one reason­­this is a truly wonderful subspecialty that is rich with benefit to the patient and replete with gratitude for the radiologist as a doctor. We are not a factory, churning out dictations, although we work very hard. We develop and offer innovative approaches to the diagnosis of breast disease. We can directly impact a woman and her family by finding a breast cancer that can be cured. The sense of well being that a breast imager has at the end of the day is far greater than the little storms that were part of that day.